Endarkening the Epistemé: Critical Race Theory and Medical Education Scholarship

The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review

BACKGROUND

Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training.

METHODS

We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform.

RESULTS

Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power.

DISCUSSION

Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

An exploration of values in medical school admissions processes: the interplay between contextual factors, admissions practices, and validity

Medical school admissions is a contentious and high stakes selection activity. Many assessment approaches are available to support selection; but how are decisions about building, monitoring, and adapting admissions systems made? What shapes the processes and practices that underpin selection decisions? We explore how these decisions are made across several Canadian medical schools, and how values shape the creation, monitoring, and adaptation of admissions systems. Using phenomenography (a qualitative method suited to examining variability), the authors analyzed interviews with 10 current or previous heads of admissions from 10 different undergraduate medical education programs in Canada. Interviews were conducted in English and French, and data was collected between 2016 and 2017 (therefore participants no longer hold these roles). Data was coded and analyzed iteratively, focusing on identifying underlying values, and exploring how these values shape admissions practices and considerations for validity. Eight different intersecting values were identified. Of these, four were shared across all participants: critically questioning the process and tools, aiming for equity, striving for better, and embracing the challenges of change. The expression of these values depended on different contextual variables (e.g., geographic location, access to expertise, resource availability), and values shaped how admissions systems were built, enacted, and monitored for quality. Ultimately, values shaped: (1) admissions practices resulting in different candidates being offered admission, and (2) how arguments supporting score interpretation are built (i.e., validity). This study documents various values that influence admissions processes, practices, and quality monitoring. The values that shape what is assessed, how it is assessed, and how fair and defensible practices are conceptualized have significant impact, ultimately determining who is selected. These values-whether implicit or explicit-result in intended and unintended consequences in selection processes. However, these values are rarely explicitly examined and questioned, leaving it uncertain as to which consequences are the intended outcomes of deliberately chosen values, and which are unintended consequences of implicitly held values of admissions systems and their actors.

"I never wanted to burn any bridges": discerning between pushing too hard and not enough in trainees' acts of professional resistance

As trainees resist social harm and injustice in medicine, they must navigate the tension between pushing too hard and risking their reputation, or not enough and risking no change at all. We explore the discernment process by examining what trainees attend to moments before and while they are resisting to understand how they manage this tension. We interviewed 18 medical trainees who shared stories of resisting social harm and injustice in their training environments. Interviews were analyzed using open and focused coding using Vinthagen and Johansson's work, which conceptualizes resistance as a dynamic process that includes an individual's subjectivity within a larger system, the context in which they find themselves, and the interactions they have with others. We framed these acts as an individuals' attempt to undermine power, while also being entangled with that power and needing it for their efforts. When deciding on how and whether to resist, trainees underwent a cost-benefit analysis weighing the potential risk against their chances at change. They considered how their acts may influence their relationship with others, whether resisting would damage personal and programmatic reputations, and the embodied and social cues of other stakeholders involved. Trainees undergo a dynamic assessment process in which they analyze large amounts of information to keep themselves safe from potential retaliation. It is by attending to these various factors in their environment that trainees are able to keep their acts professional, and continue to do this challenging work in medical education.

Student, Staff and Faculty Experience with a Medical School Racial and Sociopolitical Trauma Protocol: A Mixed Methods Study

Problem: Medical students experience racial and sociopolitical trauma that disrupts their learning and wellbeing. Intervention: University of California, San Francisco (UCSF) School of Medicine students advocated for a systems approach to responding to traumatic events. Students partnered with educators to introduce an innovative protocol that affords short-term flexibility in curricular expectations (e.g., defer attendance, assignments, assessments) to empower students to rest, gather, or pursue community advocacy work. This study explored students' protocol utilization and student, staff, and faculty experience with its implementation. Context: UCSF is a public medical school with a diverse student body. Students raised the need to acknowledge the effects of trauma on their learning and wellbeing. Consequently, students and educators created the UCSF Racial and Sociopolitical Trauma protocol ('protocol') to allow students time-limited flexibility around academic obligations following events anticipated to inflict trauma on a school community level. The protocol affords students space to process events and engage with affected communities while ensuring all students achieve school competencies and graduation requirements. Impact: We conducted a two-phase mixed methods study: (1) retrospective analysis of quantitative data on students' protocol use and (2) focus groups with students, staff, and faculty. We used descriptive statistics to summarize students' protocol use to adjust attendance, assignment submission, and assessments and thematic analysis of focus group data. Across eight protocol activations June 2020 - November 2021, 357 of 664 (54%) students used it for 501 curricular activities: 56% (n = 198) for attendance, 71% (n = 252) for assignments, and 14% (n = 51) for assessments. When deciding to utilize the protocol, student focus group participants considered sources of restoration; impact on their curricular/patient responsibilities; and their identities. The protocol symbolized an institutional value system that made students feel affirmed and staff and faculty proud. Staff and faculty initially faced implementation challenges with questions around how to apply the protocol to curricular components and how it would affect their roles; however, these questions became clearer with each protocol activation. Questions remain regarding how the protocol can be best adapted for the clerkship setting. Lessons Learned: High protocol usage and focus group data confirmed that students found value in the protocol, and staff and faculty felt invested in the protocol mission. This student-initiated intervention supports a cultural shift beyond diversity toward trauma-informed medical education. Partnership among learners and educators can contribute to transforming learning and healthcare environments by enacting systems and structures that enable all learners to thrive.

Epistemic racism in the health professions: A qualitative study with Black women in Canada

Systemic racism within health care is increasingly garnering critical attention, but to date attention to the racism experienced by health professionals themselves has been scant. In Canada, anti-Black racism may be embodied in structures, policies, institutional practices and interpersonal interactions. Epistemic racism is an aspect of systemic racism wherein the knowledge claims, ways of knowing and 'knowers' themselves are constructed as invalid, or less credible. This critical interpretive qualitative study examined the experiences of epistemic racism among 13 healthcare professionals across Canada who self-identified as Black women. It explores the ways knowledge claims and expert authority are discredited and undermined, despite the attainment of professional credentials. Three themes were identified: 1. Not being perceived or portrayed as credible health professionals; 2. Requiring invisible labour to counter professional credibility 'deficit'; and 3. Devaluing knowledge while imposing stereotypes. The Black women in our study faced routine epistemic racism. They were not afforded the position of legitimate knower, expert, authority, despite their professional credentials as physicians, nurses and occupational therapists. Their embodied cultural and community knowledges were disregarded in favour of stereotyped assumptions. Adopting the professional comportment of 'Whiteness' was one way these health care providers strived to be perceived as credible professionals. Their experiences are characteristic of 'misogynoir', a particular form of racism directed at Black women. Anti-Black epistemic racism constitutes one way Whiteness is perpetuated in health professions institutions.

Whiteness theory and the (in)visible hierarchy in medical education

CONTEXT

The theory of whiteness in medical education has largely been ignored, yet its power continues to influence learners within our medical curricula and our patients and trainees within our health systems. Its influence is even more powerful given the fact that society maintains a 'possessive investment' in its presence. In combination, these (in)visible forces create environments that favour White individuals at the exclusion of all others, and as health professions educators and researchers, we have the responsibility to uncover how and why these influences continue to pervade medical education.

PROPOSAL

To better understand how whiteness and the possessive investment in its presence create (in)visible hierarchies, we define and explore the origin of whiteness by examining whiteness studies and how we have come to have a possessive investment in its presence. Next, we provide ways in which whiteness can be studied in medical education so that it can be disruptive.

CONCLUSION

We encourage health profession educators and researchers to collectively 'make strange' our current hierarchical system by not just recognising the privileges afforded to those who are White but also recognising how these privileges are invested in and maintained. As a community, we must develop and resist established power structures to transform the current hierarchy into a more equitable system that supports everyone, not just those who are White.

Shaping undergraduate public health education through critical race theory: a case study

In 2020, the American Public Health Association declared structural racism a public health crisis acknowledging the long-lasting and harmful effects of prejudice, including relatively high rates of morbidity and mortality in many communities of color. Critical Race Theory (CRT) has become an essential lens to view and reconsider education's role in perpetuating racial and ethnic discrimination. Debates over integrating CRT in higher education with the intent to acknowledge and address racial equality and justice are more present than ever, and the discussions held in public health classrooms are no different. We present a case study of CRT integration into the Bachelor of Arts in Public Health (BAPH) program at the University of Hawai'i at Mānoa. In line with Solorzano's framework of CRT in education, initial goals of integrating CRT in instruction and advising included fostering discussions of race and racism, using a social justice framework to highlight opportunities to reduce health inequities, and validating the experiential knowledge of people of color. By engaging in active discussions with community leaders and participating in experiential learning throughout the program, students develop empathy and many underrepresented and marginalized students engage actively in their home communities. Specific examples of CRT integrated in the curriculum and examples of student projects that integrate a CRT lens are provided for educators and researchers.

"The sins of our forefathers": reimagining research in health professions education

As HPE begins to turn their attention to the lived experiences of minoritized groups in society, health professions education (HPE) researchers need to be aware of the history of social science research and the ways it contributes to creating systems of oppression. This is because as 'knowledge producers,' we make decisions about how to design our studies, analyze and interpret data, and report it in ways that are frequently oblivious to the harmful legacy of social science research, and how it continues to bring harm to minoritized communities. To not do so is to perpetuate a system that has historically served the dominant group at the expense of those who are limited in representing the world for themselves. This article proposes that HPE researchers engage in disruptive research practices by delinking with their disciplinary training, and reimagine their role in the research process. To accomplish this, I suggest that they engage in three strategies: attend to the research team's composition, embrace critical theory and investigate epistemological ignorance. These strategies are nowhere close to exhaustive, and they do not extend as far as the conversation must go in reimagining our role in the research enterprise. However, in providing some initial thoughts on this topic, I hope to invite the HPE community into discussion on how we might harness our collective responsibility to resist research practices that are harmful and unjust to minoritized communities.

A Legacy of Scientific Racism: William Osler's "An Alabama Student"

William Osler's essay "An Alabama Student" made John Young Bassett (1804-1851) a widely admired avatar of idealism in medicine. However, Bassett fiercely attacked the idea that all humans are members of the same species (known as monogenesis) and asserted that Black inferiority was a justification for slavery. Antebellum physician-anthropologists bequeathed a legacy of scientific racism that in subtler forms still runs deep in American society, including in the field of medicine.