Dialogues across difference: Teaching for social justice and inclusion in health professions education

How does one teach for social justice and inclusion? As we have advocated through our teaching and scholarship, education in this space can be most constructively framed, not through content alone, but through a process that is enriched with the interrelated concepts of dialogue, storytelling and critical consciousness. Unlike discussions or lectures, which are rooted primarily in cognitive exchange and information transfer, dialogues demand engagement of the individual as a whole person, including social and personal identities, emotions, life experiences, values and perspectives. It is fundamentally relational: an interaction in which each interlocutor brings in their own story in open-ended exploration.¹

Stories often form the basis of dialogue. As a means of communication, they provide affective bridges that span identities, origins, space and time and have the potential to foster empathy and identification. Stories can ‘make strange’—that is, twist ever so slightly the perception of taken-for-granted ideas, habits and assumptions to generate new ways of seeing—and can open up our understanding to new ways of knowing and being in the world.² In this way, the ‘cross-cultural dialogues’ that comprise this issue of the journal are effectively exchanges of stories: not necessarily in the traditional sense of having a beginning, middle and end, but in the form of ‘directions of travel’³ that are informed by experience and identities.

In engaging stories for justice, however, it is fundamentally important to ask, ‘who speaks for whom?’ and ‘whose stories are told and who is not being heard?’ Reflexivity in this context is absolutely critical. Any meaningful approach must be foregrounded in an explicit acknowledgement of one's social identities and positions of relative privilege and power. A section on reflexivity has become an essential component of qualitative research methods; however, this process requires, in our view, more than a disclosure of identities or geographic representation. It demands an acknowledgement of how those intersectional identities may influence, shape, support or even undermine the very efforts to lend voice to the dispossessed and silent. This acknowledgement is illustrated in the fundamental ambivalence and questioning that the authors express when they pose the question of whether, given their positions of privilege and power, they should be writing in this space at all.³ Indeed, much of their conversation represents a sincere and at times uncomfortable but much needed exploration of how to do the work of both scholarship and education with justice. The very idea of agency is also at the centre of the paper on inclusive assessment,⁴ especially inclusion of those with disabilities. The Disability Movement's motto of ‘nothing about us without us’⁵ resonates in this approach.

Coupled with this questioning is a matter of method. We have previously argued that learning in medical education involves different epistemologies: Learning the pathophysiologic mechanisms of complications of diabetes is a different way of knowing than understanding the root causes of increased mortality associated with diabetic complications in individuals from historically marginalized communities.^{6, 7} While the former requires knowledge and mastery of biomedical principles, in the latter, this knowledge must be tightly intertwined with an exploration of the historical, social and societal context in which diabetes is experienced and treated. In other words, a radical questioning of ‘who’ must be accompanied by an equally radical questioning of ‘why’, ‘how’ and ‘what now’? Methods aimed at capturing unique lessons across difference, must be rethought in such a way that they reveal new insights rather than reproducing existing epistemological structures of power. As Audre Lord said, ‘the master's tools will never dismantle the master's house’.⁸

In that regard, the ‘duo-ethnography’ of Frambach and van Schalkwyk³ can be considered a thoughtful, in-depth mutual interrogation of everything from the understanding each scholar has of the term ‘social justice’ to the power dynamics underlying student–supervisor interactions in postgraduate health education programmes. The exchange between Finn et al.⁴ similarly offers another example of how scholars from different backgrounds can centre their conversation on a common cause—the overarching importance of inclusive assessment in HPE—and how this value may be realized across geographic, societal and cultural differences. Both papers illustrate the power of dialogue to create, in the words of the German hermeneutic philosopher Hans Georg Gadamer, a ‘fusion of horizons’, an interplay of different identities and perspectives to open up new ways of seeing, thinking and being in the world.⁹

Both sets of authors explicitly state that they cannot claim to represent anything beyond themselves, but rather, anchor their perspectives and work within the specific contexts in which they live. In doing so, they avoid the epistemological trap of claiming to ‘represent’ the Global North and South. For contrast, consider Hofstede's model of national cultural differences, commonly used when such claims are made. Based on work done in the 1970s and 1980s, it frames behaviour, perspectives and values in terms of national characteristics and a relatively static view of culture, uninformed by such questions as history, power, intersectional identities and coloniality.^{10, 11} Hofstede's model is an example of what Walter Mignolo calls a ‘zero point perspective’, one that implicitly assumes that Western ways of knowing and being are the objective ‘zero point’ of normalcy against which all other knowledges and cultures are compared.¹²

To avoid these epistemological traps and to make health professions education, research and practice truly inclusive and just, the fostering of critical consciousness is essential. In contrast to the chiefly cognitive, analytical processes of critical thinking, critical consciousness involves a recognition of individual as conscious, reflective, social beings, coupled with an awareness of societal inequities and a commitment to address injustice.^{13, 14} Viewing medical education, including education across difference, through the lens of critical consciousness will encourage the unveiling of historical assumptions and biases, anchor efforts in the specific lived contexts of learners and teachers and allow us to be more intentional about teaching with justice. An oft-stated goal in these papers is that of creating space for teaching, learning, supervision and assessment with equity and inclusion. We would agree with these goals and believe that the overarching aim of medical education—and health care itself—is not only to eliminate suffering and oppression but to foster the conditions for human flourishing in all its forms. Paulo Freire once said that teaching is the practice of freedom,¹⁵ and we propose that the papers collected in this issue are entirely aligned with that goal.

Both the authors participated in the conceptualization, writing and editing the original draft and revision.

None for either author.

Not applicable.