Commentaries

Duncan Shrewsbury

Department of Medical Education, Brighton and Sussex Medical School, University of Brighton, Brighton, UK

In the UK, where I am based, it is estimated that 2.8% adults identify as belonging to the lesbian, gay, or bisexual (LGB) community, with a further 0.5% identifying as transgender or gender diverse (TGD).¹ In some countries, however, it is important to remember that not only is this sort of information not gathered, but it remains illegal to be lesbian, gay, bisexual transgender or queer (LGBTQ). Different versions of acronyms to refer to this heterogenous community exist (box 1) and sometimes the term ‘queer’ is used as a celebratory and inclusive umbrella term to refer to folk who do not identify as heterosexual and/or cisgendered. This is an example of a ‘reclamation’ of a pejorative slur that will be familiar, and probably still hurtful, to many in the community, necessitating sensitivity in the use of the term.

Data suggest that those in the LGBTQIA+/queer community experience disproportionately higher rates of illness. This is overwhelmingly exemplified by rates of anxiety, depression and suicidality that are experienced at rates two to ten times that seen in the general population respectively.² Other health conditions are also seen to affect people within the LGBTQIA+ community disproportionately, such as asthma affecting lesbians and breast cancer affecting lesbian and bisexual women.³ Further research to elucidate these patterns is lacking. In additional to greater healthcare needs, however, the queer community seem to experience a number of barriers to accessing healthcare, such as prejudice and discrimination from healthcare staff.² Alarmingly, up to 1 in 6 people who experience sexual orientation or gender identity change efforts (e.g. so-called ‘conversion therapy’)—which are ineffectual, traumatic and damaging—believe their ‘treatment’ was overseen or delivered by a healthcare professional.⁴ Queer colleagues and friends in the healthcare profession experience similar prejudice and discrimination, with reports suggesting that not only is this a sizeable problem, but also sadly little has changed in recent years.^5,6 This represents a pervasive issue of culture in healthcare and health professions education that must be addressed in order to provide inclusive care to the diverse communities we serve.

Studies looking into teaching about LGBTQIA+ health in undergraduate medical education suggest that very few medical schools have adequate provision in this domain, but that learners who have greater exposure tend to be able to perform more holistic history-taking, and that learners generally desire more teaching on this subject to better prepare them for professional practice.^7,8 A challenge for educators is to ensure that LGBTQIA+ peoples are represented in teaching and assessment, and that such representation is joyful rather than playing into dated and inappropriate stereotypes that perpetuate stigmatising pathologised views of queerness.

Being inclusive is an ongoing process, rather than discrete efforts or events, whereby self, environment and education are continuously examined and developed. The concept of joyful representation helps us remember that people from the LGBTQIA+ community have families, and access healthcare for matters beyond the stereotyped sexual health problems. Case studies, vignettes and scenarios used in teaching and assessment should embrace diverse formulations of patients and their kin, without their diversity being the cause or focus of the health-related problem (e.g. box 2). It is important, however, to draw on these opportunities to raise awareness of, and develop learners' skills in addressing barriers faced by queer folk. So, whilst someone's queerness may not be the reason for them accessing healthcare (as seen in box 2), their queerness may mean that the scenario involves an example of prejudice or discrimination that frustrates their healthcare journey. We need learners to be aware that this happens, and also to be prepared to be allies and engage in active bystanding to challenge and correct these pervasive barriers. Importantly, such teaching should be integrated across the length and breadth of the whole curriculum, to avoid consigning such teaching to areas of special interest (this is everyone's concern in every discipline) and to afford the opportunity to continuously develop and build awareness and skills throughout their learning journey. Developing the teaching and learning in this area represents a wonderful opportunity to engage with the community to ensure that representation is joyful and authentic, enriching teaching with narratives based on the experiences of LGBTQIA+ folk.

Many advocate that allyship starts with examining and being aware of one's own privilege: what you are and are not naturally aware of by virtue of the way your life experiences frame and inform your perception of reality.⁹ Active bystanding involves seeking to create or support some form of reparative action when one has witnessed a wrongdoing. Importantly, this does not necessarily mean jumping in with direct challenge (e.g., ‘What I just heard sounded homophobic’)—which may not be physically or psychologically safe to do for either the ally or the person being wronged. Active bystanding can involve disruption and distraction, allowing the focus of the situation to change, or affording the person being wronged the opportunity to escape (e.g., changing the subject—‘sorry, can you pass the patient's notes so I can check something’). Other forms of bystanding include a delayed approach, whereby the ally checks-in with the victim after the event, offering support and demonstrating solidarity (e.g., ‘I saw what happened earlier and thought it was awful. Are you ok? Is there anything you think I could have done, or could do now to help?’).¹⁰ As educators, we need to role model and nurture the courage and ability to adopt values of allyship and active bystanding behaviours in order to affect change in healthcare culture.

REFERENCES

1. House of Commons Library. (2023). 2021 census: what do we know about the LGBT+ population. UK Parliament.

2. Backmann, CL and Gooch, B (2018). LGBT in Britain: health report. Stonewall.

3. Landers, SJ, Mimiaga, MJ, and Conron, KJ. (2011) Sexual orientation differences in asthma correlates in a population-based sample of adults. Am J Public Health, 101(12): 2238–2241.

4. Jowett, A, Brady, G, Goodman, S, Pillinger, C, and Bradley, L. (2020) Conversion therapy: an evidence assessment and qualitative study.

5. British Medical Association and the Association of LGBT Doctors and Dentists. (2016) The experience of lesbian, gay and bisexual doctors in the NHS. British Medical Association.

6. British Medical Association and The Association of LGBT Doctors and Dentists. (2022) Sexual orientation and gender identity in the medical profession. British Medical Association.

7. Arthur, S, Jamieson, A, Cross, H, Nambiar, K and Llewellyn, CD. (2021) Medical students' awareness of health issues, attitudes and confidence about caring for lesbian, gay, bisexual and transgender patients: a cross-sectional survey. BMC Med Educ, 12; 21(1): 56, https://doi.org/10.1186/s12909-020-02409-6

8. Tollemache, N, Shrewsbury, D and Llewllyn, CD. (2021) Que(e)rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education. BMC Med Educ, 21; 21(1): 100, https://doi.org/10.1186/s12909-021-02532-y

9. Melaku, TM, Beeman, A, Smith, DG and Johnson, WB. (2020) Be a better ally. Harvard Business Review, November–December 2020.

10. Right To Be. (2022) The 5Ds of bystander intervention. Right To Be.

Adam Danquah¹ | Stephanie Bull² | Ravi Parekh²

¹Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK

²Medical Education Innovation and Research Centre, Department of Primary Care and Public Health, Imperial College, London, UK

Section A: The presentation

In my plenary session (the full transcript for which has been submitted to Medical Education), I discussed rehumanising ethnicity categorisation in healthcare education, research and practice. I wanted to bring the audience's attention to an aspect of equality, diversity, and inclusion (EDI) work that is so ingrained and procedural as to go almost unnoticed—and yet hiding a tangle of circularity, contradiction and bad science in plain sight. More than dodgy data however, I wanted to convey the negative impact on identity and belonging of taxonomising humanity without sufficient thought.

Benefits of and issues with ethnicity categorisation

I acknowledged that categorisation is what we do in healthcare science because it makes the web of pathologies and treatments manageable and brings the power of statistical analysis to bear on the data. Moreover, where healthcare equity is concerned, it provides clear and accessible evidence of unfairness we can act upon.

I cited articles that set out problems with the both the quality of such data and problems with their impact on minoritised groups but went further myself in describing a certain violence done with these categories in reducing a person so. After asking the audience to categorise themselves according to one particular reductive ethnicity data survey (taken from a UK Government website), I invited them to categorise me in the same way. The evident disquiet, I thought, spoke to this violence, quiet and symbolic maybe, but violence all the same.

I quoted Gary Younge (2023), who said, ‘A fear of being ‘pigeonholed’ is one of the most common crippling anxieties of any minority in any profession. Being seen only as the thing that makes you different by those with the power to make that difference matter really is limiting.’

Background to ethnicity categorisation

I summarised the social and psychological background to ethnicity categorisation, identifying roots in slavery, scientific racism and discussing its hardening of a social order rooted in power relations, described pithily by the group analyst Farhad Dalal (2002) as the ‘haves’ and ‘must-not-haves’.

I outlined how these structures and associated systems were alive in society and in our psyches, which contributed to the ‘stickability’ of categories that seem self-evident at times, but which we can forget are rooted in prejudice and power rather than scientific evidence.

Problems of ethnicity categorisation

From these troubling origins, I moved onto the essential problems of ethnic categories. In terms of ethnicity data surveys, I mentioned their conflations, their use of outdated terms, the small numbers of people from minoritised backgrounds in many professional bodies and organisations running the risk of ‘outing’ individuals, and exclusive terminology, increasing scope for misclassification and marginalisation. I called this a ‘double whammy’ of negative impacts on the data and the belongingness of the individuals in question.

I went on to highlight an even more fundamental problem of ethnicity categorisation; that is, despite our good intentions—that is, evidencing injustice for action—in propagating these categories we continue to (a) reify ethnicity as an essential quality rather than a social construct, and (b) associate certain ethnic categories with negativity—over and over again.

Problems of ethnicity categorisation—the case of the ‘mixed’ category

To bring these issues even more to life, I used the ‘mixed’ category that is supposed to describe my ethnicity as a case in point. I started off by quoting the poet John Agard's poem, Half-Caste, which really sums a lot of this all up over a few short stanzas starting,

‘Excuse me standing on one leg …’ https://www.youtube.com/watch?v=zDQf2Wv2L3E

Then took in: racial slurs and ethnic epithets, sperm donation, Great Replacement Theory, being asked what you are, shame, sociology, moving from reductionism to the richness of my Ghanaian-English-Irish-British heritage, acts of resistance, ‘racial fluidity’ and ONS data about an increasingly ‘mixed’ UK.

I was at pains to show that we have issues with mixedness that feed our desire for clear ethnic categorisation. I also gave a shout out to curiosity: my talk was absolutely not a condemnation of wanting to know about people and where they come from (I am a psychologist and psychotherapist after all), it simply highlighted that all curiosities are not equal: some people bear the brunt of our craving for certainty.

I said I was no longer looking for an alternative name for the mixed category, because it would just be joining the fruitless search to make the contradiction of mixing more palatable. Because when we stop to ask ourselves what exactly is being mixed, we find ethnicity data surveys positing colours (black and white), a continent (Asia), a cultural-linguistic group (Arab), and a miscellaneous bunch of anomalies (Other). I contended that the whole thing was mixed up, as were we.

Ways forward

To end the talk, I considered ways forward. I talked about (i) dispensing with the ‘Other’ category for a start and perhaps the ‘Mixed’ categories, (ii) interrogating what we are engaged in when categorising ethnicity, so we can explain to patients, participants and students, (iii) greater patient and public (PPI) involvement, (iv) owning the process, so that if we ask we ask with conviction, rather than making it the guilt/shame/anxiety-ridden affair it can be in practice (which was highlighted during a recent consultation, wherein a clinician preceded asking me for my ethnic category with the cringing, ‘Ooh, I hate this question!), and (v) rehumanising the data by becoming familiar with—that is, getting to know in real life—those (Other?) groups of people known only to us as categories on a spreadsheet. These is scope for these issues to be given greater coverage in healthcare education curricula, but it is heartening that the relevant skills of critical reflection and empathy are, exemplified, for example, in Brown, Veen and Finn's (2022) book, Applied Philosophy for Health Professions Education.

I played with the idea of going further and doing away with ethnicity categorisation altogether, but in a world characterised by healthcare inequalities, there is of course no straightforward solution.

I had some words for those that find themselves boxed in by their would-be categories, turning towards the framework of the Johari Window (e.g., https://www.skillpacks.com/johari-window-model/) as a way to consider opening yourself and others up to the everything that you are, appreciating that pigeonholing is inevitable but social support will help you navigate its constraints.

I also invited the audience to move such an inclusive view from themselves onto others and for the members to consider their power regarding whether and how to categorise in the light of all that had been shared in this session.

Section B: Responses

It was important that my talk made people think. Colleagues of (for want of a better designation) multiple heritage told me it resonated with their experiences. And healthcare educators and researchers let me know about the different ways in which they were tackling this issue. One delegate said in their study they had invited participants to self-identify their ethnicity rather than complete tick boxes and were working with the wealth of data. I then got talking to colleagues at Imperial College, who intimated their struggle to ensure they worked with meaningful categories. As an example of navigating real-world (rather than purely theoretical) constraints, their experience is instructive, and we present it here to encourage continuing working out in the community rather than our making do with ‘food for thought’.

The approach at MedIC, Imperial College.

The Medical Education Research and Innovation Centre (MEdIC) at Imperial College is a translational centre, bringing together evidence from health, education, community and policy into medical education innovations. We have a focus on ensuring medical schools play a critical role in training doctors who understand societal inequity as well as promoting access to healthcare careers for people from under-represented groups and creating inclusive educational environments.

Like many other research groups, we use research evidence that has categorised ethnicity, as well as other protected characteristics. This data has enabled us to draw attention to evidence of racial inequity and has been a key driver for change. Yet the categories used in data collection within higher education can rightly be criticised. They neither keep pace with the ways people self-identify, nor do they take into the account the many intersecting aspects of a person's life that make up their identity.

The homogenisation of participants ethnicity into dichotomous variables (‘Black, Asian, Minority Ethnic’ and White) is particularly bothersome. Often justified as being required to power statistical analyses or protect participant anonymity, yet increasingly requiring an apology for collecting and using data in this way. The MEdIC team are considering how to step away from this and acknowledge ethnicity differently within our research.

Firstly, we actively consider the rationale for collecting information about participants ethnicity. Is the rationale strong enough to warrant reporting ethnicity in a categorical way? Will the benefits outweigh the challenges and potential harms? After considering this, we often decide not to collect ethnicity information, but provide the opportunity for participants to instead, choose a pseudonym, which may be chosen by the participant to offer insight into an aspect of their identity. This may include their ethnicity if this is something that the participant wishes to emphasise, but may also relate to their gender or heritage. Where ethnicity has been a central feature of the research enquiry, the qualitative method, offers the freedom to ask broader questions about the intersection of ethnicity with other aspects of their identity, such as ‘Can you tell me about your identity and the role, if any, that ethnicity plays in this?’. This enables participants to discuss ethnicity in a way that is pertinent to them, yet still provides a focus for the research enquiry.

We have also chosen to talk about ethnicity using the term ‘ethnically minoritised’. We believe that this speaks to, rather than avoids, the structural inequities in power and privilege that Adam, and other researchers speak about (Selvarajah 2020, Fyfe 2021). Stakeholders, from ethnically minoritised backgrounds, involved in our studies have also articulated that this term is more appropriate than other options that they have encountered.

We appreciate that many of these thoughts and ideas are not new, and that there may be alternative approaches. What we hope to generate, however, is discussion about how we think about this together as a research community.

REFERENCES

M. E. L. Brown, M. Veen, G. M. Finn, eds. (2022). Applied philosophy for health professions education: a journey towards mutual understanding. Springer Nature Singapore, https://doi.org/10.1007/978-981-19-1512-3

Dalal, F. (2002). Race, colour and the processes of racialization: new perspectives from group analysis, psychoanalysis and sociology. Routledge.

Fyfe, M, Horsburgh, J, Blitz, J, Chiavoroli, N, Kumar, S, Cleland, J. The do's, don'ts, don't knows of redressing differential attainment related to race/ethnicity in medical schools. 2022. Perspectives Medical Education 11, 1–14, 1, https://doi.org/10.1007/S40037-021-00696-3

Selvarajah, S, Deivanayagam, T, Lasco, G, Scafe, S, White, A, Mkabile, W, Davakumar, D. Categorisation and minoritisation. 2020. BMJ Glob Health 5:e004508, 1-3, 12, https://doi.org/10.1136/bmjgh-2020-004508

Younge, G. (2023). Society books ‘I have no problem being regarded as a Black writer, but I won't be confined by it’: Gary Younge on race, politics and pigeonholing. The Guardian.

Funding

Sally Curtis

School Education and Admissions Tutor, University of Southampton, Southampton, UK

Introduction

I've always been a chatterbox, so the opportunity to talk about what I love and have a real passion for, was very welcome. My entire career in medical education has involved working with and learning from medical students who come from underrepresented and non-traditional backgrounds supporting access, participation, and progression through Higher Education (HE). Advocating for my students and those further afield is central to my roles in medical education, so the fantastic opportunity to deliver a keynote speech at ASME 2023 provided the perfect platform to share the student voice, and I was delighted to be able to do this alongside some of my students.

A bit of context

It's been over 25 years since the Dearing Report¹ focussed attention on increasing Widening Participation (WP) in HE in the UK, and I am delighted at the advances have been made in that time, but there is always more to do. In medicine we have seen an increase in WP students through a growing number of Gateway programmes² and contextual admission routes into medical schools, although the overall number is still low.³ This increase has been supported by targeted outreach for WP students, raising awareness of the profession and helping to prepare for applications through summer schools, virtual and in person work experience and increased information and resources.³ For many years though, it seemed the focus was simply to modestly increase numbers of students from WP backgrounds entering medical schools and that was supposed to be enough. But this approach set our students up to struggle, we did not really change or adapt our institutional systems and policies to support their needs once they entered medical school.

What do I mean by WP students?

I would like to clarify that when referring to WP medical students in this article, I am referring to students who come from backgrounds underrepresented in medicine. The main underrepresented group in the UK is low socioeconomic background and are mainly encapsulated by those on 6 year or 1 year Gateway programmes or who have entered medicine through a contextual admissions route onto a standard entry programme. However, there are many students who do not enter medical school through these routes, who are on standard entry or graduate entry programmes, who also come from underrepresented backgrounds and share the same lack of advantage and challenges. Most institutions do not have methods to readily identify them, and UKMED (the UK medical education database)⁴ has no way of recording them either. These students are therefore often overlooked by faculty staff and research studies often not receiving the same level of support as their WP peers yet share the same challenges. This is an area that could be better addressed within institutions if they were to broaden their focus and develop better identification and a greater understanding of the needs of all their students. It should also be acknowledged that there are other groups underrepresented in medicine, such as students with certain protected characteristics, which results in students with multiple intersecting identities, which can compound many of the challenges faced.

Institutional expectations—a need for change.

In undergraduate medical education and in postgraduate training, it is important that we advocate for change in our institutions to support those who do not fit the traditional medical student and trainee mould. In this profession, more than most, there is a historic expectation that our students will be from affluent backgrounds with strong social networks and connections and will have had the advantages that money and a good education, alongside a well-educated family can provide. The traditional expectations of what a student or graduate should look like, the type of capital they bring, what they sound like, has not changed with the changing demographic. There was a lot of talk of ‘levelling the playing field’ and ‘equal opportunities’ with the advent of contextual admissions, but simply giving someone a place on a medical degree does not change their background, their responsibilities, or their challenges. There is often a lack of understanding of how these factors impact on a student's or graduate's sense of belonging, ability to study and consequently their progression and career choices. Without appropriate acknowledgement and support of the challenges WP students face, we are perpetuating disadvantage, only in a different setting and under the guise of fairness. Then we wonder why our students and graduates ‘underperform’ or do not fit in, which is an example of the unchanging institutional perspective and resulting student deficit discourse.

A real bugbear of mine is the expectation that WP students should themselves strive to fit in, in other words, assimilate to the established model and change to fit the established (some would say highly outdated) view of what a medical student should be. I have worked closely with my students for over 20 years, and it brings me real joy to watch these wonderfully unique individuals enhance and enrich all our learning environments. They have provided me with copious amounts of new knowledge and understanding, which has helped me no end to do my job better and support other students more effectively. In addition, it has enhanced my own personal development and optimised my relationships with others. In medical schools, we often talk the WP talk but it's not so easy to walk the walk and truly welcome and support students and enable their authenticity and value to shine through.

Finances

No article about WP students can avoid the subject of finances. To be able to appropriately support WP students it is crucial to first understand the impact of coming from a low-income background/family and the lack of financial security. Some examples of the impact of low income include reduced access to a healthy diet, increased stress of managing, or not managing, debt, a lack of smart clothes for placement, lack of IT equipment, reduced or no access to many of extracurricular activities and social events at university and in the community. This necessitates many WP undertaking paid employment and working long hours. Students falling asleep in lectures are looked upon with disdain, lecturers often presuming they've been partying or up on their screens all night where in fact, they may be hungry or have undertaken a nightshift. We must not forget that many WP students work to financially support their families as well as themselves adding to the stress and weight of their responsibilities.

Progression and attainment

Is it any wonder, given all the challenges mentioned, that students on Gateway programmes show reduced academic attainment on entry to and exit from medical school compared to students on standard entry programmes?⁵ One of my students conducted a research project comparing the experiences of undertaking paid employment between students from low socio-economic (LSE) backgrounds and those from more financially advantaged backgrounds.⁶ The findings showed a stark difference in their priorities, with students from more advantaged backgrounds prioritising their studies, and those from LSE backgrounds prioritised survival. Many still assume that upon entering medical school, the future magically becomes bright and WP students instantly transition into the middle classes, but nothing could be further from the truth. Their futures may be potentially brighter and middle class may beckon, but first they must struggle through the unfamiliar territory of medical school, often trying to fit in with the expectations of others while keeping their heads above water academically and financially.

It is also important to realise that many of these challenges continue to be experienced by WP graduates in postgraduate training. Following the progress of the cohorts from the study that compared undergraduate outcomes,⁵ a continuation of the attainment gap and a difference in career choices when comparing Gateway graduates and their standard entry counterparts was revealed.⁷ This paper showed that Gateway graduates are less likely to pass their membership exams first time and more likely to choose General Practice (GP) as a training pathway. The latter could be considered good news as we currently have a GP shortage in the UK and we want our diverse communities to have doctors that represent them and understand the needs of their patients. However, this also brings with it some uncomfortable thoughts, such as will this lead to an expectation that Gateway and WP graduates will become GPs. Although we say it is a choice to pick a certain specialty but what factors lead them to choose GP or not choose other specialties. The cost and duration of many other specialty training courses can be prohibitive.

It has taken two decades in the UK to get enough gateway graduates in specialty training to obtain meaningful data and to start to explore their progression and retention. We now need more research to understand their experiences, the career choices WP students make and the reasons behind them. This is especially important given the serious problem with retention in the UK workforce and ever decreasing levels of job satisfaction and wellbeing of our NHS staff.

What do we mean by success?

I would suggest success is another area we need to re-evaluate considering our changing student demographic. There is no doubt about that for many years academic excellence has rightly been viewed as success, but it is not and should not be viewed the only measure of success. The culture of competition in academia pervades all areas, University and Medical School league tables and high entry requirements, with students who wins prizes, receive distinctions, or secures the prestigious training pathways being considered ‘the brightest and the best’, a phrase that particularly raises my hackles! I would like to ask you to reflect on those people who have left a real positive impression on your soul, those who have done you good. Was that a result of their A levels results or their distinction in year 2? I am not belittling academic achievement, but I would like to reposition it in the greater context of what is important in life.

My students have shown me amazing success in other ways, having to learn a new language when you come to a new country, fitting in to a new culture and way of living, and at the same time achieve good grades in your education. Similarly, students who care for parents, grandparents or siblings, day and night, and study around those responsibilities, students who must work provide income to support their family alongside undertaking their studies and achieving the grades required to get into university. Students who have experienced chronically disrupted and poor education, yet still achieving the grades they need to get to university. If we continue to view academic excellence as the greatest measure of success, we will be doing so many of our students a real disservice.

Concluding thoughts

We are clearly making progress in enabling a more diverse and representative medical profession by providing access to medical schools and to postgraduate training for students from backgrounds currently underrepresented in medicine. However, this access still remains open to relatively small numbers. I acknowledge I have not mentioned the logistical problems of selection and recruitment that stand in the way of greater change, including the lack of resources available to implement new strategies and processes that would make a greater difference. The lack of resources also affects the ability to provide the wide range of support needed throughout their studies and postgraduate training. However, we can make small but meaningful changes now. We can start to change the deficit discourse and gain a greater understanding by educating ourselves on the realities of the challenges our WP students and trainees face, by taking the time to see them, hear them and value them. One of the biggest conduits for change is taking the time to talk, to be authentic and give the students and trainees the space to be authentic too and to be understood. This is a small step that can have a massive impact.

REFERENCES

1. Dearing, R. (1997) Higher Education in the Learning Society. The National Committee of Enquiry into Higher Education. http://www.educationengland.org.uk/documents/dearing1997/dearing1997.html

2. Medical school entry requirements for 2024 start https://www.medschools.ac.uk/studying-medicine/making-an-application/entry-requirements-for-2024-start

3. Selection Alliance 2019 Report An update on the Medical Schools Council's work in selection and widening participation https://www.medschools.ac.uk/media/2608/selection-alliance-2019-report.pdf

4. UK Medical Education Database https://www.ukmed.ac.uk/

5. Curtis, S, Smith, D. A comparison of undergraduate outcomes for students from gateway courses and standard entry medicine courses. BMC Med Educ 20, 4 (2020). https://doi.org/10.1186/s12909-019-1918-y, 1

6. Anane, M. Curtis, S. Is earning detrimental to learning? Experiences of medical students from traditional and low socioeconomic backgrounds The British Student Doctor, 2022; 6(1): 14–22 https://doi.org/10.18573/bsdj.297

7. Elmansouri, A, Curtis, S, Nursaw, C. Smith, D. How do the post-graduation outcomes of students from gateway courses compare to those from standard entry medicine courses at the same medical schools?. BMC Med Educ 23, 298 (2023). https://doi.org/10.1186/s12909-023-04179-3, 1

Neera R. Jain

Centre for Medical and Health Sciences Education, Waipapa Taumata Rau – The University of Auckland, Auckland, New Zealand

Why Ableism? Why Now?

The word ‘ableism’ is appearing more frequently these days in the health professions education discourse. I increasingly see it appended to the list of ‘isms,’ the oppressive forces we must resist in our work. This delights me, because for too long ableism remained unspoken. There are good reasons for this change. A renewed focus on justice, equity, diversity, and inclusion in medicine has surged in response to recent atrocities: the murder of George Floyd, the unearthing of mass graves at Canadian residential schools, the inequitable effects of the COVID-19 pandemic.^1–5 These unsettling events have reinvigorated commitments to redressing power inequities in the field. Alongside these events, disabled learners have activated their rights under the law, advancing notions of equal access to shift practice in the field.^6–9 Perhaps most persuasive is the unavoidable reality of successful disabled physicians, who represent diversity in positionality and medical specialties.¹⁰ These movements, alongside research, organising, and activism elevating disabled learner experiences internationally, have put disability ‘on the map.’ So much so, that leading bodies have issued progressive guidance to improve access to medical education for disabled people.^11–13

Despite this narrative of progress, disabled people encounter uncertain terrain in medicine. A recent survey found disabled doctors and medical students in the UK struggled to get necessary adjustments to policy and practice, lacked a disability-inclusive culture in the field, were concerned about disclosing their disability status, and experienced bullying and harassment by colleagues.¹⁴ The survey also highlighted intersectional disparities: Black, Asian, and Minority Ethnic (BAME) people described less supportive environments than their white counterparts.¹⁴ Why do these conditions persist despite increasing visibility, recognition, success, and disclosure of disability in the medical field? I suspect this disjuncture occurs because our efforts remain at the level of ‘tinkering around the edges’—including disabled people into medicine with minor adjustments to policy and practice, but without deep contemplation of what they are being included into. Despite naming ableism as a concept to remain alert to, our efforts thus far have pruned the tree without reaching the ‘roots’ of ableism. Real change will require us to learn what ableism is, begin to see it working all around us, and find ways to eradicate it; to see its roots running through our house and begin to dissolve them.

Learning Ableism

This ‘corporeal standard’ forms a template for the ideal body and mind that is treated as normal and expected. We can think of ableism as a constellation of ideas and ways we do things that creates and then reinforces this idealised template. These ‘normal’ ways of being are privileged and the social order is organised around them.¹⁶ Ableism upholds a hierarchy that values some bodies and minds, while treating others as outsiders: disposable or excludable.^17–18

Ableism works with and reinforces other systems of power.^17,19 For example, Bailey and Mobley explain that ‘racism, sexism, and ableism share a eugenic impulse.’^{20, p. 21} We can see this in the way that ideas of ability are most readily assigned to whiteness and men, while disability and assumptions of inability have been attributed to women and people of colour to justify their denied citizenship.^21–22 Recognising the interconnections between ableism, racism, colonialism, hetero/cis/normativity, classism, and sexism demands that we examine these damaging systems of power jointly, and dismantle them collectively.¹⁸

McRuer theorises that ableism operates through a demand for compulsory ablebodiedness.²³ By situating that corporeal standard as desirable and necessary for participation, ableism compels us all to attempt to reach it. But, McRuer explains, this standard is always out of reach.²³ Yet, by constantly reaching for the standard, we entrench its dominance.²³ Through this process, ableism affects all of us, ‘disabled’ and ‘non-disabled.’ We are all subject to its expectations and we are all implicated in sustaining it. We have been socialised by it and have internalised it—probably without realising it. Expectations for bodily perfection, for proving physical and cognitive ability, for being hyper productive and capable are arguably all manifestations of ableism that are ever-present in our late capitalist societies.

Ableism becomes institutionalised when the corporeal standard is embedded in systems, policy, and practice. The clearest example is in architectural design. Consider the design of a classic lecture theatre. How does it imagine the expected users? The design reflects and produces who will use academic space: who will be presenting in an academic classroom? Who is the teacher? Who is the student? Who remains unthought of as a valid participant in such a space? In this way, we can read ableism's institutionalisation in the physical spaces of our campuses as well as our policies, practices, curricula.²⁴

Learning ableism in medical education

To learn ableism in medical education, we need to identify the taken for granted values, beliefs, and ideals about bodies and minds that are normalised—even demanded—in the field. In my research at four U.S. medical schools, I spoke to disabled students, their teachers, and school administrators.²⁵ Through these interviews, it became clear that there was a template, an expected way of being, knowing, and doing that generated friction in the work of disability inclusion. I call this the capability imperative, and I came to understand this as a way of naming ableism in medical education.^25–26 I illustrate the capability imperative through three motifs: the physician as selfless superhuman, who could be and do all things while having no personal needs; the ‘real world’ of medicine, a static vision of residency and practice environments that suggested a constrained or impossible future for disabled people in medicine; and the malleable student, who could fit the singular path through medical school.²⁶ Through these three motifs, a template for an idealised medical learner was reinforced and justified, upholding a condition of compulsory hyper-ablebodiedness and mindedness.²⁶ Disabled students and the school officials responsible for inclusion had to negotiate these cultural ideals, ultimately constraining what was possible.²⁵ The capability imperative is just one way of illustrating ableism in medical education, developed in the US context. More work is needed to understand how ableism works in other national contexts and from differing perspectives.

Unlearning ableism, towards transformation

We have some distance yet to travel to realise a truly inclusive medical education. Naming ableism is insufficient while institutionalised ableism continues to subvert our vision for greater inclusivity. To move forward, we must interrogate whether the values currently centred in medical education, such as the capability imperative, align with our professed ideals. If not, we must determine what values ought to replace these and how our systems must shift in kind—we must unlearn ableism. Such a transformation can seek to reshape medical education from disabled ways of being, knowing, and doing. First and foremost, this transformational work must be led by disabled people, their knowledge and experience.¹⁸ But disabled people must not be saddled with responsibility for change; we all must claim this responsibility.

REFERENCES

1. Amster, EJ. The past, present and future of race and colonialism in medicine. CMAJ 2022; 194(20): E708–E710, https://doi.org/10.1503/cmaj.212103

2. Doebrich, A, Quirici, M, Lunsford, C. COVID-19 and the need for disability conscious medical education, training, and practice. J Paediatric Rehabilitation Medicine 2020; 13(3): 393–404, https://doi.org/10.3233/PRM-200763

3. Naidu, T. Modern medicine is a colonial artefact: introducing decoloniality to medical education research. Acad Med 2021; 96(11S): S9–S12, https://doi.org/10.1097/ACM.0000000000004339

4. Slavin, S. Is medical education systemically racist? J Natl Med Assoc 2022; 114(5): 498–503, https://doi.org/10.1016/j.jnma.2022.06.002

5. Thambinathan, V, Kinsella, EA. When I say … anti-racist praxis. Med Educ 2023; 57(6): 511–513, https://doi.org/10.1111/medu.14997

6. Eligon, J. Deaf student, denied interpreter by medical school, draws focus of advocates.New York Times [Internet]. 2013 August 20 [cited 2023 Jul 31]. Available from: https://www.nytimes.com/2013/08/20/us/deaf-student-denied-interpreter-by-medical-school-draws-focus-of-advocates.html

7. Gulli, C. Diversity among doctors: Students with disabilities are finding their place in medical school-and beyond. Maclean's [Internet]. 2015 Sept 25 [cited 2023 Jul 31]. Available from: https://macleans.ca/education/post-graduate/breaking-down-barriers-for-med-students-with-disabilities/

8. Kohrman, N. We need more doctors with disabilities. Slate [Internet]. 2017 Jul 5 [cited 2023 Jul 31]. Available from: https://slate.com/technology/2017/07/increasing-the-number-of-doctors-with-disabilities-would-improve-health-care.html

9. LM Meeks, NR Jain, EP Laird, editors. Equal access for students with disabilities: The guide for health science and professional education. New York (NY): Springer Publishing; 2020, https://doi.org/10.1891/9780826182234

10. Meeks, LM. DocsWithDisabilities Podcast. Available from: https://www.docswithdisabilities.org/docswithpodcast

11. GMC. Welcomed and valued: Supporting disabled learners in medical education and training. [Internet]. GMC; 2019. Available from: https://www.gmc-uk.org/-/media/documents/welcomed-and-valued-2021-english_pdf-86053468.pdf

12. Medical Deans Australia New Zealand. Inclusive medical education: Guidance on medical program applicants and students with a disability. [Internet]. MDANZ; 2021. Available from: https://medicaldeans.org.au/md/2021/04/Inclusive-Medical-Education-Guidance-on-medical-program-applicants-and-students-with-a-disability-Apr-2021-1.pdf

13. Meeks, LM, Jain, NR. Accessibility, inclusion, and action in medical education: Lived experiences of learners and physicians with disabilities. [Internet]. AAMC; 2018. Available from: https://store.aamc.org/accessibility-inclusion-and-action-in-medical-education-lived-experiences-of-learners-and-physicians-with-disabilities.html

14. BMA. Disability in the medical profession: Survey findings 2020. [Internet]. BMA; 2010. Available from: https://www.bma.org.uk/media/2923/bma-disability-in-the-medical-profession.pdf

15. Campbell, FK. Inciting legal fictions: Disability's date with ontology and the ableist body of the law. Griffith Law Review 2001; 42: 42–62.

16. Campbell, FK. Contours of ableism: The production of disability and abledness. Basingstoke, Hampshire: Palgrave Macmillan; 2009, https://doi.org/10.1057/9780230245181

17. Lewis, TL. Talila, A Lewis blog [Internet]. Unknown: Talila A. Lews. Working definition of ableism – January 2022 update. 2022 1 [cited 2023 July 31].

18. Sins Invalid. Skin tooth and bone: the basis of our movement is people. Berkeley, CA: Sins Invalid; 2019.

19. Annamma, SA, Connor, D, Ferri, B. Dis/ability critical race studies (DisCrit): theorising at the intersections of race and dis/ability. Race Ethn Educ 2013; 16(1): 1–31, https://doi.org/10.1080/13613324.2012.730511

20. Bailey, M, Mobley, IA. Work in the intersections: a Black feminist disability framework. Gend Soc 2019; 33(1): 19–40, https://doi.org/10.1177/0891243218801523

21. Baynton, DC. Disability and the justification of inequality in American history. In: PK Longmore, L Umansky, editors. The New Disability History: American Perspectives. NYU Press; 2001. p. 33–57.

22. Erevelles, N, Minear, A. Unspeakable offences: untangling race and disability in discourses of intersectionality. Journal of Literary & Cultural Disability Studies 2010; 4(2): 127–146, https://doi.org/10.3828/jlcds.2010.11

23. McRuer, R. Crip theory. New York, NY: NYU Press; 2006.

24. Hutcheon, EJ, Wolbring, G. Voices of ‘disabled’ post secondary students: examining higher education ‘disability’ policy using an ableism lens. Journal of Diversity in Higher Education 2012; 5(1): 39–49, https://doi.org/10.1037/a0027002

25. Jain, NR. Negotiating the capability imperative: Enacting disability inclusion in medical education. [doctoral thesis on the Internet]. Auckland (NZ): University of Auckland; 2020 [cited 2023 July 31]. Available from: http://hdl.handle.net/2292/53629

26. Jain, NR. The capability imperative: theorizing ableism in medical education. Soc Sci Med 2022; 315:115549, https://doi.org/10.1016/j.socscimed.2022.115549

27. Razack, S, McKivett, A, Carvalho Filho, MA. Challenging epistemological hegemonies: researching inequity and discrimination in health professions education. In J Cleland, SJ Durning, editors. Researching medical education. 2^nd ed. John Wiley & Sons Ltd. 175–185, https://doi.org/10.1002/9781119839446.ch16

28. Hoskins, TK, Jones, A. Indigenising our universities. [Internet]. E-Tangata. 2023 Available: https://e-tangata.co.nz/comment-and-analysis/indigenising-our-universities/

29. Donald, CA, DasGupta, S, Metzl, JM, Eckstrand, KL. Queer frontiers in medicine. Acad Med 2017; 92(3): 345–350, https://doi.org/10.1097/ACM.0000000000001533

30. Hrynyk, N, Peel, JK, Grace, D, Lajoie, J, Ng-Kamstra, J, Kuper, A, Carter, M, Lorello, GR Queer (ing) medical spaces: queer theory as a framework for transformative social change in anesthesiology and critical care medicine. Can J Anaesthesia 2023; 70(6): 950–962, https://doi.org/10.1007/s12630-023-02449-8

31. Zaidi, Z, Young, M, Balmer, DF, Park, YS. Endarkening the epistemé: critical race theory and medical education scholarship. Acad Med 2021; 96(11S): Si-Sv, https://doi.org/10.1097/ACM.0000000000004373

R. J. Cullum | S. Curtis | N. R. Jain | V. D. Nadarajah

TASME TiME is a freely available Medical Education Scholarship Podcast. To celebrate our first birthday, we were joined by Professor Sally Curtis, Dr Neera Jain, and Professor Vishna Nadarajah for a panel discussion about the importance of intersectionality. Here, we present a summary of our discussion, with the full episode available on podcasting platforms.

What does intersectionality mean to you?

Vishna

For me, intersectionality means who I am. I am a person of Sri Lankan Tamil heritage. So that forms a part of me, my culture, even my religion. I am also Malaysian. I grew up in a multi-racial country where the majority are Muslims. Hence, I feel that I identify very well in multicultural environments and enjoy working with different communities. I am also a medical educator with International Partnership Programmes. So, I also feel I'm global. As intersectionality is who I am, that forms who I am as a person and medical educator.

Neera

I would like to answer by attending to the theory and why it matters. Intersectionality is about acknowledging complexity. So, Dr Kimberle Crenshaw, a Black woman and legal scholar, developed this idea because in her legal work,¹ she noticed that human rights protections did not get at the nuances of marginalisation. If we look just at individual categories of marginalisation, it's not enough because when those categories come together, there's a different experience. If we are just looking at Blackness, gender, class separately, we are not getting at the hierarchies within those categories. We must attend to how people experience for example, ableism differently. If we are only thinking about ableism, without thinking about racism, or sexism, or classism, then some people will continually be left at the bottom.

Sally

Another perspective on this is understanding what other people's intersectional identities are. We make so many assumptions, but many of our identities are not apparent. I see around me the expectation of people to behave or respond in particular ways that align with that observer's own identity. If you can take time to understand somebody, and find out who they are, things are a lot easier for everybody. People do not feel as marginalised, or overlooked, or misunderstood. A lot of the difficulties and challenges my students face are because people do not understand their identities and how they relate to a given situation.

Tips for getting to know the intersectional identities of our learners and teams

Vishna

I think intersectionality must not be a tick box. This is where countries could do better. Any form we fill there are separate sections on gender, nationality, religion or whether you are able or not. How that data is used to understand communities, and make communities work together is missing. That's similar even in medical education, we can improve how data on students' intersectional identities are used to benefit the student learning environment. Personal tips, I would say be brave, genuine and interested in intersectional identities, but be sensitive to the context. If you're going to ask and discuss identities, do that follow up conversation and maybe acknowledge some of your own ignorance. Also share your intersectionality—it cannot be a one-way conversation. This is when you really get to know a person.

Neera

I think learning people's intersectional identities is something that must be earned. Sometimes that's going to come out over time. I think about teams that I'm a part of and that idea of reflexivity—it's important to reflect on who we are. What do we bring to this work? I think all researchers should be thinking about who are we? How does this affect how we see the world what we can see, what cannot we see? How is that going to affect the work that we produce? And that doesn't mean one can't do work because of their identity. But it's about thinking critically about what does it mean for us to do this work? Are there perspectives that are missing? This is so important for research teams, thinking about the knowledge they're generating, and where that's coming from.

Sally

It can be difficult when you first meet someone. We deliver a three-hour session with our students to sit down to get to know each other in a safe way, where people draw their identities. It's derived from a family therapy method. You share only what you feel comfortable sharing. You present important aspects of your identity to your group. Some people draw flags, some people draw their family, some people draw religious symbols. For example, I would draw a glass half full, because I'm an optimist and I will explain what that means and why that's me. After each identity has been presented, everyone is invited to ask questions to that person. It's really powerful but takes time. However, if you really want to know people, and you really want to work as a team, you need to take a bit of time. I think, to be authentic, to share yourself, but absolutely to take time and to be respectful, and have that two-way dialogue is really helpful.

How do we reduce the burden on marginalised people to educate others on issues of intersectionality?

Vishna

This has been also on my mind, how to reduce the burden for marginalised persons. We cannot expect certain groups to always be explaining themselves. For example, for someone who is brown or black and a patient doesn't want to interact with you, it should not be the burden of that person to correct the situation. It happens in every part of the world, where marginalised persons will be at the bottom of the ladder. Hence allies are important. We cannot just think of allies as someone who is the educator or the clinician, although their allyship should be explicit. Allies also can be peers that support one another. They are persons that recognises their own privilege and will work together to correct difficult situations.

Neera

This is a sticky area. The adage, ‘Nothing about us without us’ is instructive. It's foundational that the work we do in this space is led by those with lived experience. But what that leadership looks like might differ, because not everyone wants to be an advocate. There is often a smaller group of people who have put themselves out there, who are then really burdened with labour. One thing that I always recommend is to first do the work yourself. There's so many resources where people have already put their stories out there. We should read those, educate ourselves. By doing some of that baseline work, then you are coming to a conversation more informed. Then, I think making space for those folks to take care of themselves, to not be on every committee. We must also acknowledge the work that they're doing, for example, in what counts towards academic promotion. I think of our Indigenous faculty who are asked to do so much around language and culture, looking at people's grant applications to ensure culturally safe practice. That work should be recognised and weighted accordingly.

How do we address intersectionality within minority groups?

Neera

This is such a real and prevalent concern. I think about students who participated in my research—Black disabled women in medicine. They discussed not being able to talk about disability within a Black students' association space. I think in movement spaces, we need to be thinking about intersectionality as a core value. Without intersectionality, it waters down what we are able to achieve. If you are someone who wants intersectionality valued and you are willing to step forward, maybe raise it as a topic for the group to discuss together?

Sally

I do not want our widening participation students to lose their uniqueness when they come into medical school. We do not want them to assimilate into the stereotype of ‘medical student’. It's their uniqueness that brings value to the learning environment. It's our responsibility to create an environment where people can come and authentically be themselves, where everyone is heard.

Vishna

I'm going to bring Star Trek into this. The Borg is a group collective, they assimilate, so they lose their identity. I've lived in the Netherlands, and the UK, and I did feel I had to assimilate and lose some of my intersectional identity. Even now, I'm so conscious of how I speak because I have a Malaysian accent. I was really ashamed of it, because I thought that it made me look less professional academically. I used to hear George Alagiah speak on the BBC, and I thought, if I could only speak with such diction and clarity. But over time, people gave me encouragement, I gained that confidence. I'm not saying that it's easy, but at least for me, just being myself, and showing it through my work and actions worked. I would say do not assimilate, resist. Resistance is not futile! Resist as much as you can to maintain that identity, because not only you become richer, but so does the community.

How can we apply intersectionality theory in our research?

Vishna

I have a role as the deputy editor in a journal. One of the things that we look for is the reflexivity and how that intersectionality is being discussed and acknowledged. This helps research scholarship because it changes the lens and gives readers a broader perspective. With the refocus of intersectionality in scholarship, we can soon see the impact on papers that are being published, we want our readers and authors to know their intersectional identities are being valued.

Neera

There's a great paper that Tasha Wyatt and colleagues have written on intersectionality—they emphasise that it needs to come in at the start of research.² I've experienced this in my doctoral work. Historically in disability in medicine, it was quite rare for students of colour to come forward to participate in research. But in my research, I had a lot of students of colour. It highlighted for me how I hadn't prepared for that. As a researcher, tuning into the data you're getting, but also the data you're not getting, is something to consider. To not assume that students of colour don't exist in the space that you're working in, thinking about your sampling strategy.

Sally

Slightly deviating from the question, something we are going to bring into our admissions and selection training, is that at the beginning of each process is to say, what is my position? What am I looking for? What lens am I looking through? Rather than doing a standard EDI training package several months before they interview, we want to bring in some checks and balances in individual's thought process.

If we were to come back together in 5 years' time, where do you hope we will be?

Vishna

I hope we are not in Birmingham, but somewhere else in the world, having the same conversation with an even more diverse group. Hopefully we can do it in a sustainable manner though especially with our carbon footprint. Importantly in 5 years the medical education community needs to grow and become more global, because that is a reflection of society of, we live in. Where should we be in 5 years' time in terms of scholarship? I think it's still evolving. Perhaps developing more literature globally and evaluating evidence because there is a big paucity in that. Importantly sharing evidence and impact that a diverse workforce works for healthcare is crucial. This is because I think there are a lot of detractors out there who still do not think these issues are real.

Sally

In the words of one of my colleagues from the widening participation directorate at the University, he hopes he's out of a job. It would be really nice not to need widening participation programmes to medicine. But I do not think that's going to happen. We've got a system that was built on what it was thought doctors should look like. It'd be really nice to have programmes that accommodate all students from all backgrounds that can help them realise their potential. Hopefully, we will see a much larger proportion of our medical students coming from widening participation backgrounds.

Neera

I used to say I hope I do not need to do this research anymore. I think that's kind of the ideal world, we do not need to be talking about equity, diversity, inclusion, and justice, because it's already deeply embedded. But I think we are always working towards a horizon, which means it's always moving. There's always going to be new things that we are recognising that we were not talking about. So, I hope we are in a place where we can see more things to be working towards.

REFERENCES

1. Crenshaw, Kimberlé ‘ Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics,’ University of Chicago Legal Forum: Vol. 1989: Iss. 1, Article 8. Available at: http://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8

2. Wyatt, TR, Johnson, M, Zaidi, Z. Intersectionality: a means for centering power and oppression in research. Adv Health Sci Educ Theory Pract 2022; 27(3): 863–875. https://doi.org/10.1007/s10459-022-10110-0

Megan E. L. Brown¹ | Gabrielle M. Finn²

¹School of Medical Sciences, University of Newcastle, Newcastle, UK

²Division of Medical Education, School of Medical Sciences, The University of Manchester, Manchester, UK

Medicine, and medical education, are all too-often about conforming to established systems and processes. We, as medical educators and researchers, take great care in ensuring learners gain high levels of factual knowledge, are clinically competent, and are skilled communicators. Challenging the status quo, a critical component of advocacy that is necessary to improve the inclusivity of medicine and medical education (Singh, 2022), is seldom a priority of medical curricula, particularly for early-stage medical students (Castillo et al. 2020). Where advocacy is a focus, this is often limited to student-selected electives or extra-curricular activities that only a small subset of students have access to (Brender et al. 2021).

As in previous years, ASME offered the ENRICH programme at our Annual Scholarship Meeting (ASM) 2023 (George., 2022). ENRICH offers a selected number of free conference places for A-Level students in the local area of where the annual conference will be held. By enabling students to attend our ASM we provide an opportunity for networking with current health professions students, as well as clinicians and academics attending the conference. This is an invaluable experience for students to gain an understanding of the landscape of health professions education, to experience a professional work environment, as well as gain exposure to the research and pedagogic innovations presented. For us to truly challenge the status quo, and develop health advocacy at a grassroots level, engaging students before they enter medical school is imperative. Students, such as those on our Enrich programme, are the future leaders and policymakers.

One participant, Emily Taylor, reflects on her experience below:

‘Attending the ASME 2023 conference developed my understanding of how progressive modern healthcare has become. It challenged what it truly means to be a physician, and questioned who benefits from things remaining the way they are in the current healthcare system. The varying perspectives surrounding marginalisation gave me vital insight into the importance of camaraderie within the healthcare workforce, free from judgement or stigma. I have been able to integrate this growth mindset into my values and encourage others to do the same, heavily inspired by the multitude of experiences shared at the conference. I have come to realise that talent comes in endless, diverse forms that all contribute to improving the work environment and standard of patient care. Through the Enrich programme, I was able to explore the realities of a future in medicine via impactful discussions with like-minded doctors. This is an invaluable opportunity, teaching me skills within networking and professionalism, as well as building on my understanding of the roles and responsibilities that I aspire to undertake. I have come to appreciate that EDI is the responsibility of all and am grateful to become a part of this optimistic future. Following the conference, I now feel immeasurably more motivated to pursue a career in medicine, and will use the impactful reflections that I have made throughout my journey. I encourage all students in a similar position to me to apply for this unique opportunity, and I hope that it continues to motivate aspiring students for years to come.’

Emily Taylor—Enrich Student, The Coleshill School

“The ASME ENRICH programme was all about, nurturing aspirations in individuals regardless of background. There is an indescribable element of medicine that truly fascinates me, and I am sure that it is what I will spend my life doing: this event offered me a chance to cement this even further whilst truly delving into what it is in medicine that makes it perfect to me. It may be considered foolish by some to study one of the most competitive degrees, leading to an extremely high-demand job, whilst coming from a background such as mine, however I know this is what I want to do.”

Rae Anyidoho – Enrich Student, Madeley Academy

“This opportunity solidified my overall determination into doing medicine as a future career and allow me to perceive certain situations from a doctor's perspective through critical thinking and will provide me with a clear insight and overview of Medicine. It was amazing!”

Fenoon Mohammed – Enrich Student, Swanshurst School

“The ASME annual conference provided me with an invaluable opportunity to enrich my interest and delve further into the world of healthcare beyond recreational reading. The conference exposed me to the importance of diversity in healthcare, especially to patient trust, recruitment of our wonderful doctors and rooting out the causes of healthcare disparities within the UK. Thank you so much for this opportunity!”

Omio Bhattacharjee – Enrich Student, King Edward VI School

We hope you will agree that Emily's reflection is rich, and powerful. Her insights cast light on the far-reaching impact of early exposure to the principles of equality, diversity, and inclusion for aspiring medical learners. Imbuing learners with critical motivation is the first step to critical consciousness development, as we have outlined in the theoretical framework of this commentary. Emily's experiences showcase the development of critical motivation. The enthusiasm and inquisitiveness of her reflection demonstrate that she is a learner motivated to question existing structural and cultural norms within healthcare. Emily reflects on the power of interacting with like-minded professionals, and engaging with the complex issues of health equity and social justice. Through her reflection, her motivation to participate in these conversations, rather than observe, becomes evident. This critical motivation is the foundation of critical consciousness that will enable Emily to progress to critical reflection and action, at an early stage of her medical career.

It is our responsibility, as medical educators and researchers, to support and nourish critical reflection at an early stage of learners' education. Learners, on entry to medical school, may bring with them experiences that have already inspired critical motivation, reflection, and action, and we must not stymie these efforts. For other learners, facilitating experiences which inspire critical motivation will be key. Whether through outreach programmes like Enrich, or curricula reform within medical school, we must continue to make steps to inspire critical consciousness development among learners. We would suggest that, despite repeated calls for advocacy to be embedded within medical curricula, many organisations are yet to make sufficient changes to action this critical need. We hope that ASME ASM 2023 attendees will feel inspired to make, and advocate for, necessary changes to their curricula so that learners are supported to develop their critical consciousness, and advocacy skills as part of critical action. Health inequalities for many minoritised communities have worsened since Ojo et al.'s call for reform in 2020—now, in 2023, the call for equity and justice in healthcare is not just loud, it is thundering.

REFERENCES

Brender, T.D., Plinke, W., Arora, V.M. and Zhu, J.M., 2021. Prevalence and characteristics of advocacy curricula in US medical schools. Acad Med, 96(11), pp. 1586–1591, https://doi.org/10.1097/ACM.0000000000004173

Brown, M.E. and George, R.E., 2023. Supporting critically conscious integrated care: a toolbox for the health professions. Clin Teach, p.e13569, 20, 4, https://doi.org/10.1111/tct.13569

Castillo, E.G., Isom, J., DeBonis, K.L., Jordan, A., Braslow, J.T. and Rohrbaugh, R., 2020. Reconsidering systems-based practice: advancing structural competency, health equity, and social responsibility in graduate medical education. Academic Medicine: Journal of the Association of American Medical Colleges, 95(12), p. 1817, 1822, https://doi.org/10.1097/ACM.0000000000003559

Diemer, M. A., Rapa, L. J., Voight, A. M., & McWhirter, E. H. (2016). Critical consciousness: a developmental approach to addressing marginalisation and oppression. Child Development Perspectives, 10(4), 216–221. https://doi.org/10.1111/cdep.12193

Freire, P. Pedagogy of the oppressed New York: Herder and Herder; 1972.

George, R. E. (2022). Embedding equality, diversity and inclusivity at ASME. Clin Teach, 19, e13538, S2, https://doi.org/10.1111/tct.13538

Ojo, A., Sandoval, R.S., Soled, D. and Stewart, A., 2020. No longer an elective pursuit: the importance of physician advocacy in everyday medicine. Health Affairs Forefront

Singh, N.K., 2022. Translating ideals into practice: a pragmatic approach to advocacy for medical trainees. Acad Med, 97(6), pp. 771–772, https://doi.org/10.1097/ACM.0000000000004485

Vishna Devi V Nadarajah

There are several reasons for making global diversity and inclusion (DI) a priority in medical education research (MER). The first reason relates to the position and value of medical education. It is a caretaker to two important and interlinked sectors higher education and healthcare. From the social determinants of health perspective, individuals and communities with accessibility to higher education and healthcare have better health outcomes (Hahn, 2021). Medical education accessibility in educational desserts or marginalized communities provides not only accessible healthcare services but opportunities for students in either urban or rural areas to have access to higher education and be part of the future healthcare workforce (Soemantri et al, 2020). A diverse and competent healthcare workforce mirroring the changing socio-demographic needs of its biggest stakeholders, patients and communities, should be a priority for higher education and healthcare. The second reason relates to increasing evidence of the benefits of DI initiatives or adverse effects when it is absent. The lack of DI initiatives in medical education can have an impact on the personal and professional development of a student or healthcare professional (Nadarajah et al., 2023; Hodkinson et al., 2022). Effective and available DI initiatives will positively enable personal development of individuals and their own wellbeing which in turn enable better delivery of healthcare services. Reason three for DI in medical education is the concept of diversity and inclusion is contextual and constantly changing. Medical education when delivered in higher education institutions, healthcare facilities or in community settings needs to make explicit to both learners and practitioners that context matters, with cultural awareness and sensitivity as necessary competencies for a safe practitioner.

The above-mentioned reasons highlight that DI is integral to medical education and it follows that medical education research (MER) should also be based on the tenets of DI too. Additionally, from Boyer’s scholarship of teaching and learning framework (Kern et al., 2015), including DI tenets in MER could catalyse and benefit community-engaged scholarship and public engagement by institutions (Sdvizhkov et al., 2022). There are, however, barriers to DI initiatives in MER especially at the global level. A common global barrier is how medical education research is valued compared to other clinical and health sciences disciplines in medical schools and their institutions. Nevertheless, there are barriers within the MER community that need to be acknowledged, reflected and acted upon. These barriers include the dominance of the western knowledge structures, epistemologies, scientific methods and expertise in MER (Naidu et al., 2023). Whether the cause of this dominance is due to the historical development of medical education, colonialism, language, research priorities, research expertise or resources, one clear outcome is, it impacts how MER from non-western settings is viewed, valued and engaged. Evidence of this is seen in the significantly lower number of publications, citations, editorial board members or conference keynote roles from non-western countries in medical education (Meo et al 2019 ;Nadarajah, 2021; Wondimagegn et al., 2023).

In recent years there have been more positive conversations, reflective publications and calls for action around these geographical inequities in MER (Naidu, 2021; Wondimagegn et al., 2023). However, there is a worry, that this momentum and call for a truly global community of practice would slowly fade as unwittingly barriers are put up due to individual and institutional protectionism or return to old practices because we are afraid of change, easily citing the fallback excuse that these are quality and standards we are familiar with. The fallback can prevent efforts to invest in talent development and align MER to healthcare outcomes. In non-western settings will it widen the gap for inclusion with missed opportunities to form communities of practice and collaborate globally. It is ironic or simplistic, we are excited about travel, culture and food from around the world, why are we not curious and eager to learn from settings that are different from ours? Do institutional leaders understand that there will be net gains for higher education and healthcare if MER enables and pushes the boundaries with more diverse and inclusive knowledge structures and epistemologies.

It is in this environment; I ask myself who am I as a medical educator or institutional leader? It has felt like ‘we know more about them (the west) than they would know about us’. What role do I play in perpetuating these inequities and how can barriers be reduced? Honestly why should it be them and us, if we are truly committed to advancing medical education and healthcare in our increasingly interlinked world, wouldn’t it be beneficial to reach out and to tackle these wicked problems together. We can continue to bridge the gap in global MER by:

a. Valuing the diverse geographical and sociocultural narratives in medical education: broaden literature search, conversations and international medical education networks.

b. Question biases: check assumptions that studies (contextually different) have less rigour, relevance and not up to ‘western’ standards.

c. Demonstrate learning from others: through more diverse citations, inclusion criteria in reviews or research studies and use of less negative language to describe concepts from the global south.

d. Recognize the impact of privilege: access (or lack of) to publications and language support, open access funding or when collaborating in MER, ask who should tell the story?

e. Build capacity and not borrow for MER: faculty develop for MER at both individual and institutional level, equitably balancing academic mentoring or research supervision with content and contextual expertise.

f. Celebrate Global Diversity and Inclusion: this includes celebrating our own intersectionality to appreciate others, to develop authentic dialogues and relationships.

In summary, we must persist in posing questions for the advancement of MER and equitable recognition of global knowledge and expertise. This not only involves global diversity and inclusion (DI), which is the focal point of this commentary, but also demands a respectful acknowledgement that context, similarities and differences matters for diversity and inclusion priorities.

Note: This commentary is a summary of one part of the ASME 2023 Gold Medal plenary. The other part provides a lens into medical education in Southeast Asia with the aim to increase global MER engagement by introducing the diversity and richness of medical education initiatives in the region.

ACKNOWLEDGEMENT

I would like to thank Professors Gabrielle Finn, Veena Singaram, Ardi Findyartini, Er Hui Meng and Viktoria Goddard for their insightful feedback for this commentary.

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