Teaching and Learning in Medicine最新文献

Research is never truly neutral; all research is inherently subjective because it is shaped by who conducts it, how they think, and the systems they operate within. Paradoxically, despite reflexivity's critical intent - a practice for recognizing and addressing researcher influence - it too often becomes a superficial checkbox exercise that fails to meaningfully challenge deeper structural and systemic inequities. As a result, Health Professions Education (HPE) research often reinforces global power imbalances, privileging Western perspectives while excluding knowledge from the Global South and marginalized communities. This article advocates for Critical Reflexive Praxis (CRP), an approach grounded in Critical Theory, that combines self-reflection with deliberate action to disrupt power dynamics and promote equity in research. CRP extends beyond traditional reflexivity by interrogating and transforming the underlying structures that shape knowledge production and dominant research practice. By adopting CRP, researchers can challenge entrenched hierarchies, include and amplify marginalized perspectives, and create research that fosters meaningful social transformation. This article offers practical guidelines for enacting CRP across individual, interpersonal, local, and global levels during HPE research planning, paving the way for more equitable and impactful contributions to HPE and beyond.

Introduction: Physicians from racially and ethnically minoritized (REM) populations are woefully under-represented in the medical profession. The consequences of under-representation are far reaching, with profound impacts on social justice efforts and public health. One solution to remedy this crisis involves the aggressive recruitment of students from REM backgrounds. Though medical education programs have advanced in the recruitment of REM students, their outcomes during medical school are worse than for students from non-REM populations. Previously, literature has focused on causes for this disparity including social determinants, biases, and burden. Approach: In this manuscript, we invoke Critical Whiteness Theory (CWT) to argue how the systems of assessment in medical schools are an under-appreciated contributor to disparities, effectively perpetuating inequities by promoting a white supremacist culture. We begin by examining the origins of assessment in medical education, exploring the historical desire to measure attributes of a good doctor, but the tendency to default toward measures of aptitude and rote medical content knowledge that support a white supremacist culture. The Flexner Report and a systemic shift to favor standardized testing are highlighted as major contributors to the foundation of medical school assessment programs. We then describe potential for progress, through a better definition of the good doctor, articulated by the competency-based medical education movement, and advanced further through a justice-oriented assessment program. Findings: Using an illustrative case example and review of the literature, we suggest that progress in admissions and remediation are commonly coupled, and misaligned, with a historical approach to assessment. Resulting from the misalignment, we argue that medical education programs effectively "gaslight" REM students by admitting them into programs poorly equipped to support their success and convincing REM students that their poor outcomes were earned. We share examples from pre-clinical and clinical assessment programs, including a continued reliance on standardized tests, arbitrary grading thresholds, shadow assessment programs, and focus on episodic remediation that results in stigmatization for failures. Insights: We conclude by providing a model for how issues identified through this perspective may be remedied through a justice-oriented approach to assessment. Through that approach, we propose improved alignment in the recruitment and retention of REM students, thereby resulting in better outcomes for patients, improved physician representation, and realization of a diverse and more complete picture of the good doctor.

Traditional student evaluations of teaching and educator portfolios do not adequately assess the breadth and depth of medical educators' efforts. Current processes use limited perspectives, focus on a small portion of educators' work, and emphasize subjective opinions, which introduce bias. Use of these data for high-stakes decisions such as academic promotion contributes to inequitable career advancement. We propose a holistic, growth-focused, behaviorally anchored system of evaluation which incorporates perspectives of the learner, peers, and self, and which examines the full scale of educator activities from a single session, to course design, to development of educator skills over years.

Self-regulated learning (SRL) can significantly improve academic achievement and clinical performance. The clinical clerkship is a crucial setting for reinforcing and extending SRL skills and behaviors into clinical practice. However, learning in clinical settings is often opportunistic and contextual, requiring diverse instructional strategies and tailored learning opportunities. Studies from the past two decades have indicated challenges in implementing SRL strategies particularly in Asian countries. While many of the pedagogical approaches used in medical education include aspects of SRL theory, a comprehensive overview of effective SRL instructional strategies in clinical clerkships is lacking. We reviewed all studies (published between January 2012 and May 2024, identified via systematic search of EBSCOhost, PubMed, ScienceDirect, Scopus, and Web of Science) that discuss instructional strategies influencing SRL among clinical clerkship students, in general, and with special reference to the Asian context. Twenty seven articles were included in the final analysis. We conducted convergent integrated synthesis on the data extracted from all included studies to generate categories and themes. SRL instructional strategies reported included implementing learning plans and goal setting, operationalizing formal mentoring and feedback processes, utilizing technology-enhanced learning, facilitating collaborative group learning, providing simulation-based learning experiences, and applying experiential learning strategies. When implemented effectively, such strategies were shown to promote self-regulated learning, motivational beliefs, self-monitoring, and self-reflection. Faculty support, mentoring and timely feedback were crucial in successfully implementing SRL strategies. Incorporating SRL into existing curricula was ideal for ensuring feasibility and long-term sustainability. Limited research from the Asian region indicates that SRL has not been used to its full potential in Asian medical education. Asian medical students' SRL potential could be maximized with shared roles of students and teachers in a student-driven approach. Medical educators should take responsibility for providing opportunities and a conducive environment to foster SRL among clinical clerkship students. Future research should prioritize longitudinal, experimental studies with comparison groups and objective SRL outcome measures to rigorously evaluate the impact of instructional strategies in the clinical clerkship context.

The healthcare workforce in the United States does not provide the same standard of care for people with disabilities as for nondisabled people. Many academic medical institutions do not routinely offer disability-conscious medical training, and many clinicians and medical educators feel ill-equipped to incorporate anti-ableist learning goals into their curricula. Drawing on a critical review of the literature and interviews with medical educators, representatives of professional organizations, and disability advocates, this article presents promising practices for disability-conscious undergraduate medical education. Disability-conscious education, which is grounded in the insights of disability studies and disability rights and justice frameworks, is distinguished from disability-specific education, which may not extend beyond biomedical models of disability. First, we define current approaches to teaching about disability, highlighting limitations and opportunities for further development. We then identify and analyze approaches to teaching about disability that support the development of disability consciousness among learners. With attention to both curricular format and theoretical frameworks, we offer concrete approaches that medical schools can take to equip students with the knowledge, attitudes, skills, and practices they need to provide equitable care for patients with disabilities.

Phenomenon: Sexual and gender minority (SGM) identifying individuals experience worse health outcomes compared to non-SGM identifying counterparts. Representation of SGM individuals within medical schools may improve the delivery of more equitable healthcare through reducing biases and normalizing SGM presence within healthcare spaces. Approach: Our initial aim was to explore the extent to which role models may influence personal SGM identities within medical schools in the United Kingdom, using an interpretative phenomenological approach. This methodology allowed us to develop meaning from, and give voice to participants' relationship with their bespoke experiences, respecting differing narratives within the broad 'SGM' umbrella, rather than attempting to establish commonalities. Semi-structured interviews were conducted with five medical students and three medical school faculty within three medical schools, who identified as SGM. Due to a lack of gender minority identifying participants, we unfortunately could not adequately speak to their experiences, and therefore narrowed our eventual focus to sexual minority (SM) individuals. Findings: The developed themes followed a cyclical process of: (1) role model identification; (2) role model selection, influenced by matched wider identities including generation, hierarchy and power; (3) trait assimilation, particularly where identity deficits were perceived; and (4) identity projection, where students used role models to both emulate comfortable SM identity projection, and become advocatory role models themselves. Throughout, participants described role models as multifaceted in their direction (vertical and horizontal), influence (positive and negative) and locus of effect (as individuals, and as part of a collective). Unexpectedly, identity, power, and hierarchy-matching meant peer-to-peer role modeling was often experienced more positively than vertical faculty-to-student role modeling. However, as expected, heteronormativity exerted an inhibitory effect on this process. Insights: We built upon existing social cognitive paradigms to develop a 'double-funnel' model to represent how social contexts can map onto individual SM identities and vice versa, mediated by role models. The triangulation of these three aspects in relation to medical education presents novel understandings to the field. Greater explicit institutional support of student-led SM societies, and facilitation of the presence and discussion of SM symbols and personal identities within professional spaces, may go a long way in redefining 'normativity' in medical schools.

The involvement of people with lived experience (patients) in medical education offers a unique opportunity for students and residents to access personal and collective knowledge about the lived experience of health, ill health, and medical care. Involvement also has the potential to elevate the role of people with lived experience and their knowledge within medicine by providing a model for meaningful collaboration and partnership. However, involvement has been critiqued by critical disability scholars for its potential to harm without leading to meaningful change in professional knowledge or practice. In this article, we (two educators with lived experience and an academic psychiatrist) describe the development and delivery of an annual lived-experience presentation about psychosis for the second-year class of a large, urban medical school in Canada. We describe our reflexive process attempting to enact meaningful involvement and disrupt the uneven power relations that shape and constrain this work, in a setting where the risks of exploitation, tokenism, and co-optation are significant. Our goal has been to re-imagine the "patient panel," which puts significant limits on the position of patients as knowers. By re-defining roles and shifting power from faculty to lived experience educators, we have aimed to present important non-medical ideas about psychosis and how to effectively support people who experience it, while disrupting interpersonal and structural bias.

Phenomenon: There is a crucial need to more deeply understand the impact and etiology of bias toward persons with developmental disabilities (PWDD). A largely unstudied area of concern and possible intervention is the portrayal of PWDD in medical education. Often, medical photographs portray PWDD with obscured faces, emotionless, and posed in an undignified way. This exploratory, qualitative study aimed to explore how photo representations of PWDD influences medical students' attitudes and beliefs toward disability. Approach: We recruited 10 medical students from a single medical school in the northeastern United States to participate in in-depth, individual semi-structured interviews via Zoom. During the interviews, we asked students to reflect on and respond to two image sets of PWDD: a standard image set, which were photos from medical textbooks, and a positive image set, which were photos from the U.S.-based disability nonprofit, Positive Exposure. Using thematic analysis underpinned by the Health Stigma and Discrimination Framework, we coded and organized the transcripts into four themes that characterized participants' attitudes and beliefs about PWDD. Findings: The four themes we identified were as follows. Humanization vs. dehumanization: Standard imagery characteristics (e.g., black bars, unnatural posing, lack of clothing) were perceived as dehumanizing and raised concerns about consent and autonomy, whereas positive imagery characteristics (e.g., clothing, natural poses, nonclinical settings) were seen as humanizing and enhanced perceptions of agency. Quality of life: Standard imagery often led to assumptions of compromised quality of life, while positive imagery suggested a good quality of life. Discomfort vs. comfort with communication in a clinical setting: Dehumanizing portrayals increased perceived difficulty in establishing rapport, while humanizing imagery mitigated these perceived barriers. Diversity: Image sets showcasing a diverse spectrum of presentations for a given diagnosis were valued for medical education. Insights: We conclude that photographic representation of disability in medical education can influence medical students' attitudes and beliefs about PWDD. Photographic elements can either humanize or dehumanize, with humanizing representation leading to more positive attitudes and therefore also an educational benefit. Thoughtful and inclusive visual content is needed in medical education to encourage positive attitudes and foster a more empathetic healthcare environment. Our results support future plans to further investigate how photo representation affects attitudes in a larger sample. Additionally, our study's insights contribute to the ongoing initiative Textbook Beauty, providing guidance for the selection of photography to improve attitudes toward disabilities.

Issue: Asians have experienced a rise in racialized hate crimes due to the anti-Asian rhetoric that has accompanied the COVID-19 pandemic. However, there has been little acknowledgement of anti-Asian discrimination within the medical education community. While anti-Asian hate is not new or unfamiliar to us, four authors of Asian descent, it has given us an opportunity to reflect on how we have been complicit in and resistant to the larger racial narratives that circulate in our communities.

Evidence: In this article, we provide a brief history of Asians in the Americas with a focus on anti-Asian hate. Next, while presenting stories from the perspective of Asian medical education researchers who were born/have settled in the U.S. and Canada, we take the opportunity to reflect on how our personal experiences have shaped our perceptions of ourselves, and the representations of Asians in the field of medicine.

Implications: We hope to create awareness about how stereotypes of success tied to Asians can be used as a tool of oppression creating strife between Black communities, Asian communities, and other people of color. There is a need to develop critical consciousness to address the issues of equity in academia and in clinical practice.

Phenomenon: Ad hoc entrustment decisions reflect a clinical supervisor's estimation of the amount of supervision a trainee needs to successfully complete a task in the moment. These decisions have important consequences for patient safety, trainee learning, and preparation for independent practice. Determinants of these decisions have previously been described but have not been well described for acute care contexts such as critical care and emergency medicine. The ad hoc entrustment of trainees caring for vulnerable patient populations is a high-stakes decision that may differ from other contexts. Critically ill patients and children are vulnerable patient populations, making the ad hoc entrustment of a pediatric critical care medicine (PCCM) fellow a particularly high-stakes decision. This study sought to characterize how ad hoc entrustment decisions are made for PCCM fellows through faculty ratings of vignettes. The authors investigated how acuity, relationship, training level, and task interact to influence ad hoc entrustment decisions. Approach: A survey containing 16 vignettes that varied by four traits (acuity, relationship, training level, and task) was distributed to U.S. faculty of pediatric critical care fellowships in 2020. Respondents determined an entrustment level for each case and provided demographic data. Entrustment ratings were dichotomized by "high entrustment" versus "low entrustment" (direct supervision or observation only). The authors used logistic regression to evaluate the individual and interactive effects of the four traits on dichotomized entrustment ratings. Findings: One hundred seventy-eight respondents from 30 institutions completed the survey (44% institutional response rate). Acuity, relationship, and task all significantly influenced the entrustment level selected but did not interact. Faculty most frequently selected "direct supervision" as the entrustment level for vignettes, including for 24% of vignettes describing fellows in their final year of training. Faculty rated the majority of vignettes (61%) as "low entrustment." There was no relationship between faculty or institutional demographics and the entrustment level selected. Insights: As has been found in summative entrustment for pediatrics, internal medicine, and surgery trainees, PCCM fellows often rated at or below the "direct supervision" level of ad hoc entrustment. This may relate to declining opportunities to practice procedures, a culture of low trust propensity among the specialty, and/or variation in interpretation of entrustment scales.