Dialogues on the Threshold: Dialogical Learning for Humanism and Justice

From understanding to embracing: A guide on emotions in medical education research: AMEE Guide No. 184

Emotions refer to conscious and subjectively experienced mental reactions that are often associated with physiological and behavioral changes. In the context of medical education research, emotions have a pervasive influence on how various types of information are perceived and processed, and therefore, can influence how research is designed, conducted, and implemented. While there is considerable research on how emotions affect learning, there is little guidance for researchers on how to recognize and potentially leverage emotions while conducting and disseminating medical education research. Emotions can be potentially beneficial for fostering a stronger connection to research, increasing motivation to conduct sensitive research, and enhancing reflexivity and rigor. In this guide, the authors describe how emotions may influence medical education research while assisting researchers on how to recognize and manage emotions during the research process. This guide builds upon existing research to provide a framework for emotional reflexivity in the context of medical education research.

Seeing Ourselves in Others: Understanding and Addressing Biases in Medical School Admissions Processes

Purpose

Medical school admissions is a vital area for advancing diversity, equity, and inclusion (DEI). Integrating bias recognition and management (BRM) within the context of admissions is critical in advancing DEI. However, there is a dearth of empirically informed literature on BRM in the admissions context. Therefore, this study sought to explore how individuals involved in admissions decisions process and integrate bias related feedback.

Methods

The authors conducted a qualitative exploratory study using constructivist grounded theory. 21 semi-structured interviews were conducted with various participants in the admissions process at a North American medical school who had participated in bias related training. Participants included medical school faculty, senior medical students, and community volunteers.

Results

Overall, participants expressed diverse perspectives on their personal biases and how these biases impact admissions decisions. Their reflections were shaped by their identities, values, and priorities, which varied based on whether they were faculty members, students, or community members. Participants also highlighted that their biases influenced their perceptions of the ideal admissions candidate, thus influencing their decision-making process. They emphasized the need for more opportunities to engage in dialogue with peers to openly share and discuss how to recognize and manage their biases.

Conclusion

Our study suggests that fostering critical reflection about identity tensions, building and sustaining a community of practice, and facilitating sustained dialogue may provide admissions committees with an evidence-informed, meaningful, and sustained approach to advancing DEI through bias recognition and management.

The violence of curriculum: Dismantling systemic racism, colonisation and indigenous erasure within medical education

BACKGROUND

Epistemic violence is enacted in medical curricula in mundane ways all the time, negatively impacting learners, teachers and patients. In this article, we address three forms of such violence: White supremacy, indigenous erasure and heteronormativity.

METHODS

In this article, we examine the knowledge systems of medicine as a global phenomenon, impacted by Western and European ideologies of race and colonisation, both produced by them, helping to reproduce them through authoritative and hegemonic ideologies. We seek not only to problematise but also to propose alternative teaching approaches rooted in the Global South and in Indigenous ways of knowing. Taking inspiration from Paulo Freire, we advocate for the development of critical consciousness through the integration of critical pedagogies of love, emancipation and shared humanity. Drawing on Irihapeti Ramsden, we advocate for cultural safety, which emphasises power relations and historical trauma in the clinical encounter and calls for a rights-based approach in medical education. Deliberately holding space for our own vulnerabilities and that of our students requires what Megan Boler calls a pedagogy of discomfort.

CONCLUSIONS AND SIGNIFICANCE

Our perspectives converge on the importance of critical consciousness development for culturally safe practice in medical education, acknowledging the need to emphasise a curriculum of shared humanity, introducing the concept of Ubuntu from Southern Africa. Ubuntu can be encapsulated in the phrase 'I am because we are', and it promotes a collective approach to medical education in which there is active solidarity between the profession and the diverse populations which it serves.

An Educational Framework for Healthcare Ethics Consultation to Approach Structural Stigma in Mental Health and Substance Use Health

This paper addresses the need for, and ultimately proposes, an educational framework to develop competencies in attending to ethical issues in mental health and substance use health (MHSUH) in healthcare ethics consultation (HCEC). Given the prevalence and stigma associated with MHSUH, it is crucial for healthcare ethicists to approach such matters skillfully. A literature review was conducted in the areas of bioethics, health professions education, and stigma studies, followed by quality improvement interviews with content experts to gather feedback on the framework's strengths, limitations, and anticipated utility. The proposed framework describes three key concepts: first, integrating self-reflexive practices into formal, informal, and hidden curricula; second, embedding structural humility into teaching methods and contexts of learning; and third, striking a balance between critical consciousness and compassion in dialogue. The proposed educational framework has the potential to help HCEC learners enhance their understanding and awareness of ethical issues related to structural stigma and MHSUH. Moreover, context-specific learning, particularly in MHSUH, can play a significant role in promoting competency-building among healthcare ethicists, allowing them to address issues of social justice effectively in their practice. Further dialogue is encouraged within the healthcare ethics community to further develop the concepts described in this framework.

A systematic scoping review of group reflection in medical education

BACKGROUND

Reviewing experiences and recognizing the impact of personal and professional views and emotions upon conduct shapes a physician's professional and personal development, molding their professional identity formation (PIF). Poor appreciation on the role of reflection, shortages in trained tutors and inadequate 'protected time' for reflections in packed medical curricula has hindered its integration into medical education. Group reflection could be a viable alternative to individual reflections; however, this nascent practice requires further study.

METHODS

A Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure a review of group reflections in medical education. Independent searches of articles published between 1st January 2000 and 30th June 2022 in bibliographic and grey literature databases were carried out. Included articles were analysed separately using thematic and content analysis, and combined into categories and themes. The themes/categories created were compared with the tabulated summaries of included articles to create domains that framed the synthesis of the discussion.

RESULTS

1141 abstracts were reviewed, 193 full-text articles were appraised and 66 articles were included and the domains identified were theories; indications; types; structure; and benefits and challenges of group reflections.

CONCLUSIONS

Scaffolded by current approaches to individual reflections and theories and inculcated with nuanced adaptations from other medical practices, this SSR in SEBA suggests that structured group reflections may fill current gaps in training. However, design and assessment of the evidence-based structuring of group reflections proposed here must be the focus of future study.

Hearing the voices of midwives through reflective writing journals: Qualitative research on an educational intervention for Respectful Maternity Care in Zimbabwe

Women attending public and private sector health facilities in Africa have reported abuse and neglect during childbirth, which carries a risk of poor health outcomes. We explored from the midwives' perspective the influence of an educational intervention in changing the attitudes, behaviour and practices of a group of midwives in Zimbabwe, using transformative learning theory as the conceptual framework. The twelve-week educational intervention motivating for Respectful Maternity Care consisted of a two-day workshop and five follow-up sessions every two weeks. Thematic analysis was conducted on eighteen reflective journals written by the midwives with member-checking during follow-up discussions and a further one-day participative workshop a year later. The midwives reported being more women-centred, with involvement of birth companions and use of different labour positions, stronger professional pride and agency, collaborative decision-making and less hierarchical relationships which persisted over the year. Their journal narratives included examples of treating birthing women with more compassion. Some categories aligned with the phases of transformative learning theory (self-examination of prior experience, building of competence and self-confidence into new roles and relationships). Others related to improving communications and effective teamwork, providing role-models of good behaviour, use of scientific knowledge to inform practice and demonstrating competence in management of complex cases. This study shows that innovative educational initiatives have the potential to change the way midwives work together, even in challenging physical environments, leading to a shared vision for the quality of service they want to provide, to improve health outcomes and to develop life-long learning skills.

From skillful to empathic: evaluating shifts in medical students' perceptions of surgeons through a combined patient as teacher and arts-based reflection program

Introduction

The purpose of this study was to identify whether the incorporation of a combined Patient as teacher (PAT) and arts-based reflection (ABR) program during a surgical clerkship rotation could influence more humanistic perceptions of surgeons, using an innovative evaluation approach.

Methods

A novel, single question evaluation tool was created. Third year medical-students were asked to "list the top 5 attributes of a surgeon, in order of perceived importance" both before and after their surgical clerkship rotations and participation in the PAT/ABR program. Attributes identified by students were coded as either "humanistic" or "non-humanistic," which were then analyzed using generalized linear regression models under a Bayesian framework.

Results

After participation in the PAT/ABR program, the predicted probability of students ranking a humanistic characteristic as the most important attribute of a surgeon had increased by 17%, and the predicted probability of students ranking a humanistic characteristic amongst their top three attributes for a surgeon had increased by 21%.

Conclusion

This innovative evaluative method suggested the success of a combined PAT/ABR program in encouraging a humanistic perspective of surgery and this approach could potentially be explored to evaluate other humanistic education initiatives.

Examining the Impact of Dialogic Learning on Critically Reflective Practice

PURPOSE

While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies.

METHOD

In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective.

RESULTS

The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences.

CONCLUSIONS

The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

Teaching poverty and health: importing transformative learning into the structures and paradigms of medical education

BACKGROUND

As a paradigm of education that emphasizes equity and social justice, transformative education aims to improve societal structures by inspiring learners to become agents of social change. In an attempt to contribute to transformative education, the University of Toronto MD program implemented a workshop on poverty and health that included tutors with lived experience of poverty. This research aimed to examine how tutors, as members of a group that faces structural oppression, understood their participation in the workshop.

METHODS

This research drew on qualitative case study methodology and interview data, using the concept of transformative education to direct data analysis and interpretation.

RESULTS

Our findings centred around two broad themes: misalignments between transformative learning and the structures of medical education; and unintended consequences of transformative education within the dominant paradigms of medical education. These misalignments and unintended consequences provided insight into how courses operating within the structures, hierarchies and paradigms of medical education may be limited in their potential to contribute to transformative education.

CONCLUSIONS

To be truly transformative, medical education must be willing to try to modify structures that reinforce oppression rather than integrating marginalized persons into educational processes that maintain social inequity.

Discomfort, Doubt, and the Edge of Learning

Discomfort is a constant presence in the practice of medicine and an oft-ignored feature of medical education. Nonetheless, if approached with thoughtfulness, patience, and understanding, discomfort may play a critical role in the education of physicians who practice with excellence, compassion, and justice. Taking Plato's notion of aporia-a moment of discomfort, perplexity, or impasse-as a starting point, the author follows the meandering path of aporia through Western philosophy and educational theory to argue for the importance of discomfort in opening up and orienting perspectives toward just and humanistic practice. Practical applications of this approach include problem-posing questions (from the work of Brazilian education theorist Paulo Freire), exercises to "make strange" beliefs and assumptions that are taken for granted, and the use of stories-especially stories without endings-all of which may prompt reflection and dialogical exchange. Framing this type of teaching and learning in Russian psychologist L.S. Vygotsky's theories of development, the author proposes that mentorship and dialogical interactions may help learners to navigate through moments of discomfort and uncertainty and extend the edge of learning. This approach may give birth to a zone of proximal development that is enriched with explorations of self, others, and the world.

The KAIROS Blanket Exercise: Engaging Indigenous ways of knowing to foster critical consciousness in medical education

PURPOSE

Indigenous Peoples across Turtle Island (North America) experience ongoing health disparities tied to the effects of colonization and persistent racism toward Indigenous Peoples. Educating future clinicians to develop a critical consciousness is an important way to work toward cultural safety and improve the health care experiences of Indigenous patients. The present study evaluated the ability of the KAIROS Blanket Exercise (KBE) to foster critical consciousness.

METHODS

Two hundred thirteen medical students at the University of Toronto participated in the KBE. Subsequently, 174 students completed a paper evaluation, designed to capture concepts of cultural safety and critical consciousness. Data were analyzed using quantitative and qualitative methods to identify shifts in perspectives.

RESULTS

The majority of students reported the exercise altered the way they viewed those from backgrounds different from their own, and comments regarding bias, power and privilege were highlighted throughout the responses. Engaging in critical reflection through dialogue and revealing the complex sociopolitical context of Indigenous Peoples' history were emphasized as central to this transformation.

CONCLUSIONS

Following participation in the KBE, medical students demonstrated a shift in their perspectives. This suggests that creating curricular space for critical pedagogy may be effective in fostering critical consciousness, ultimately encouraging reflexive practice and social action.

The Role of the Chief Resident in Promoting Health Equity

Drawing on recent experiences as a Chief Resident, the author proposes several strategies for promoting health equity. Challenges to this task are highlighted. The Chief Resident's ability to bypass these obstacles and construct experiences that promote long-term change is explored through the framework of the formal, informal, and hidden curricula. The strategic use of didactic conferences, role-modeling, and personnel decisions are emphasized.

A qualitative study of patients' and caregivers' perspectives on educating healthcare providers

BACKGROUND

Patients/caregivers can be actively involved in the education of healthcare providers (HCPs). The purpose of this study was to explore patients'/caregivers' perspectives on their involvement and roles in the education of HCPs.

METHODS

We invited patients/caregivers to participate in one-on-one semi-structured interviews. We analyzed the interview data using conventional content analysis to identify themes.

RESULTS

In terms of patient/caregiver involvement in the education of HCPs, we identified that patients/caregivers perceive that it: (a) is challenging because of power-differentials between themselves and HCPs; (b) requires patient training; (c) needs to start early in HCPs' education processes; (d) can improve patient-HCP partnerships; and (e) requires compensation for patients. With regards to the roles that patients can play in educating HCPs, we found that patients/caregivers want to: (a) teach HCPs about patients' expectations, experiences and perspectives through case studies, storytelling, and educational research; (b) provide direct feedback to HCPs; and (c) advise on curricula development and admission boards for HCPs.

CONCLUSIONS

Understanding patients'/caregivers' perspectives on this topic can help educational leaders and HCPs improve active patient/caregiver involvement in the education of HCPs. We need to listen to patients'/caregivers' voices in order to make effective changes in current and future health professions education.

Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond

This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.

Building Structural Empathy to Marshal Critical Education into Compassionate Practice: Evaluation of a Medical School Critical Race Theory Course

Ideas of racial genetic determinism, though unsupported by scientific evidence and atavistic, are common and readily apparent in American medical education. These theories of biologic essentialism have documented negative effects in learners, including increased measures of racial prejudice.

From hermeneutics to heteroglossia: 'The Patient's View' revisited

This article explores conceptual and methodological challenges surrounding the recovery of patients' voices in the history of medicine. We examine the debate that followed Roy Porter's seminal article, 'The Patient's View: Doing Medical History from Below' (1985). Porter argued that patients should be given a central role in medical history, aiming to restore to patients a voice and agency that is often lost in 'physician-centered' historical narratives. His work carried significant influence but also sparked an ongoing debate about the possibility of conducting 'patient-centered' history of medicine. The growth of the medical humanities has afforded renewed attention to patient narratives, supporting the need to recognise patients' voices in contemporary healthcare and medical education. However, several barriers complicate and problematise the expansion of a patient-centred epistemology across historical periods. Postmodern critics have expressed scepticism that 'the patient's view' can be recovered from history, with some claiming that 'the patient' is a construct of the 'medical gaze' whose subjectivity cannot be reconstituted outside of sociohistorical discourses of knowledge and power. Psychiatry in the mid-20th century presents a particular challenge for patient-centred history. We discuss the influence of postmodern theorists, especially Michel Foucault, whose work is seen as undermining the possibility of a patient-centred epistemology. We argue against Foucault's erasure of the patient, and instead explore alternate constructivist epistemologies, focusing on the hermeneutics of Hans-Georg Gadamer and dialogism of Mikhail Bakhtin, to help address historiographical challenges in recovering 'the patient's view'. To illustrate the value of Gadamerian and Bakhtinian approaches, we apply them to a case study from the Verdun Protestant Hospital (Québec, Canada) from 1941 to 1956, which sheds light on the introduction of the first antipsychotic, chlorpromazine, into clinical practice. We highlight how Gadamer's hermeneutics and Bakhtin's dialogism together offer insights into patient perspectives during this liminal period in the history of psychiatry.

What is "shared" in shared decision-making? Philosophical perspectives, epistemic justice, and implications for health professions education

BACKGROUND

Drawing from the philosophical work of Hans-Georg Gadamer and the perspectives of theorists Mikhail Bakhtin and Kenneth Burke, the aim of this paper is to critically reflect on the meaning of the word "shared."

METHOD

The authors draw on the concept of epistemic justice, which they argue permeates the clinical encounter, to discuss how various forms of, and claims to, knowledge may influence the attainement of shared decision-making in health care contexts. The specific objectives are twofold: first, the authors draw key concepts from key Gadamerian, Burkean, and Bakhtinian philosophical perspectives to consider shared decision-making in relation to two types of epistemic injustice: testimonial and hermeneutic epistemic injustice. Second, building on philosopher Paulo Freire's critical pedagogy, the authors emphasize that major changes in educational structures and systems are required to promote the critical reflexivity required to address issues of epistemic justice, in the broader pursuit of authentic shared decision-making.

RESULTS

They propose three main areas of focus for helath professions education: (a) changes in content (moving from a focus on biomedical knowledge to more content on social sciences) and methods of teaching (more dialogue and the creation of moments of dissonance); (b) a re-examination of teachers' role in promoting epistemic justice; and (c) inclusion of patients as partners.

CONCLUSIONS

Without major transformation in what, how, and with whom we teach, future clinicians may be unprepared to enact shared decision-making in a manner that does justice to the various ways of knowing.

A Matter of Trust

Trust is a fundamental tenet of the patient-physician relationship and is central to providing person-centered care. Because trust is profoundly relational and social, building trust requires navigation around issues of power, perceptions of competence, and the pervasive influence of unconscious bias-processes that are inherently complex and challenging for learners, even under the best of circumstances. The authors examine several of these challenges related to building trust in the patient-physician relationship. They also explore trust in the student-teacher relationship. In an era of competency-based medical education, a learner has the additional duty to be perceived as "entrustable" to 2 parties: the patient and the preceptor. Dialogue, a relational form of communication, can provide a framework for the development of trust. By engaging people as individuals in understanding each other's perspectives, values, and goals, dialogue ultimately strengthens the patient-physician relationship. In promoting a sense of agency in the learner, dialogue also strengthens the student-teacher relationship by fostering trust in oneself through development of a voice of one's own.

A Dialogic Approach to Teaching Person-Centered Care in Graduate Medical Education

BACKGROUND

Training future physicians to provide compassionate, equitable, person-centered care remains a challenge for medical educators. Dialogues offer an opportunity to extend person-centered education into clinical care. In contrast to discussions, dialogues encourage the sharing of authority, expertise, and perspectives to promote new ways of understanding oneself and the world. The best methods for implementing dialogic teaching in graduate medical education have not been identified.

OBJECTIVE

We developed and implemented a co-constructed faculty development program to promote dialogic teaching and learning in graduate medical education.

METHODS

Beginning in April 2017, we co-constructed, with a pilot working group (PWG) of physician teachers, ways to prepare for and implement dialogic teaching in clinical settings. We kept detailed implementation notes and interviewed PWG members. Data were iteratively co-analyzed using a qualitative description approach within a constructivist paradigm. Ongoing analysis informed iterative changes to the faculty development program and dialogic education model. Patient and learner advisers provided practical guidance.

RESULTS

The concepts and practice of dialogic teaching resonated with PWG members. However, they indicated that dialogic teaching was easier to learn about than to implement, citing insufficient time, lack of space, and other structural issues as barriers. Patient and learner advisers provided insights that deepened design, implementation, and eventual evaluation of the education model by sharing experiences related to person-centered care.

CONCLUSIONS

While PWG members found that the faculty development program supported the implementation of dialogic teaching, successfully enabling this approach requires expertise, willingness, and support to teach knowledge and skills not traditionally included in medical curricula.