By: Ming-Ka Chan (@MKChan_RCPSC) and Jamiu Busari (@jobusar)
Imagine what it would take to ensure that we had the most inequitable and unjust health professions education system. Usually, when asked to respond to such a ‘worst-case scenario’ as part of a TRIZ exercise, you get a few nervous laughs, and then the ideas start flowing. TRIZ is a type of liberating structure used to surface barriers to change or improvement. It’s usually easy to get creative, and the aim isn’t about solving a problem or finding blame. When considering this worst-case scenario in a competency-based medical education (CBME) environment, the following ideas might come to mind:
- Curricula (milestones and entrustable professional activities) and care practices that are biased and do not meet the needs of learners nor patients, their caregivers & communities (therefore, not meeting our social accountability mandate);
- Biased and prejudiced curriculum developers and faculty;
- Unskilled and incompetent or dis-competent faculty in the space of social justice – unable to manage situations where learners experience microaggressions;
- Competence committees and educational leaders that are not representative of the learners;
- Fixed mindset;
- Psychologically unsafe environments where no one feels comfortable speaking up because of oppression and othering (a sense that they don’t belong);
- A mismatch between learning and assessment—lack of clarity of expectations;
- Unmanageable numbers and frequency of EPA assessments that are not driven by learner objectives;
- Absent or unhelpful written comments on assessments;
- Absent or meaningless (verbal) feedback.
While by no means comprehensive, this list starts us thinking about whose lens we are looking through when we consider inequity and injustice and how intricately linked the healthcare and education systems are. We need to consider the scenario from a micro-meso-macro perspective, i.e., individual/interpersonal, team/group/organization, and system levels. Some issues on this list are specific to CBME, but most, one could argue, could be part of any education system – in medicine, across the health professions, or in general.
The next phase of a typical 3-part TRIZ is, to be honest about how close this worst-case scenario list is to our reality. Which ones on the list are we doing? Or perhaps the better question is which ones aren’t we doing? For example, no one can deny that they have biases. Biases are the beliefs, ideas, assumptions, and stories that form from culture, experiences, and the influence of others. Biases influence how we see or treat others and how we value and interpret information. Biases can appear in every part of CBME – from the assumptions made that can lead to diagnostic errors to the conformity-based recruitment practices that limit creativity. Also, it extends from the differential expectations based on intersectionality to faculty diversity that does not reflect the learner groups nor the patients/communities they serve. Management of microaggression is an area of dis-competence for many faculty – how many of us pre-meet with learners to discuss individual preferences for how faculty should respond when learners experience microaggressions? And if learners feel that biases surround them, how do they feel psychologically safe in their learning and work environments? Will they see their growth potential, or do they develop fixed mindsets? Furthermore, systemic racism is a fixed mindset and remains entrenched in medical and health professions education.
In part 3 of the TRIZ, we then consider which items we have the power to stop, modify or improve in the short and long term. This phase of the TRIZ is where we can be solution focused. So, what is needed to get to an equitable and just health care and education system?
To guide the process of choosing the proper steps, we need to have a shared understanding of some concepts central to the conversation and how they are interrelated. First, social justice is a political and philosophical theory that focuses on “fairness in relation” between individuals in society and the “equal access” to wealth, opportunities, and social privileges. Meanwhile, CBME is an educational approach that prepares physicians for practice by focusing on outcome abilities during and after medical training (Frank et al., 2010). Based on societal and patient needs, these abilities are expected to promote greater accountability, flexibility, and learner-centeredness in physicians. Having clarified these concepts, applying a social justice lens to CBME entails that instructors and learners experience fairness in educational interactions during medical training. It also suggests that learners have a sense of equal (and equitable) access to educational growth and development opportunities. This “equal access” goes beyond direct (bias-related) obstacles many experience as individuals, including infrastructural, technological, and cultural determinants of CBME. Further, current insights in CBME suggest that the benefits may be skewed, with some learners and learning environments missing out on the true values and objectives of CBME (Tweed 2021; Freeman 2016).
Hence, we propose that a “just” CBME educational framework should demand critical consciousness from faculty and curriculum developers when choosing their implementation strategies (Jemal, 2017). Specifically, to start, it would involve:
- Increasing awareness of (implicit) biases in our educational systems and promoting (mandatory) bias training for learners, instructors, assessors, competence committee members, leaders, etc. The implicit association test is a valuable training tool to start this process.
- Deconstructing rigid and fixed mindsets and promoting learning models/approaches that are generative and transformational. Explicitly apply these approaches in the clinical workplace when providing feedback or when approaching learners with difficulty during competency committee meetings.
- Promoting representation that makes a difference. Deliberately building diversity into the processes, structures, and composition of faculty, competence committees, academic coaches, institutional leadership, etc., is an essential first step.
In our opinion, achieving a CBME framework that is just, and fair would require us to safeguard the educational growth and promotion of learners throughout the continuum of medical training and practice. We work towards this social justice goal by increasing awareness of the inherent (implicit) biases in ourselves and our educational systems, promoting growth mindsets, and ensuring truly inclusive representation. Such representation starts with managing the leaky pipeline in medical and health professions education. This a phenomenon that causes underrepresented and systemically disadvantaged learners (and faculty) to fail to reach their full potential (Freeman 2016). For CBME to be truly just, it should be accessible and welcoming to all in any context.
About the authors:
Ming-Ka Chan, MD, MHPE, FRCPC, is Co-Director, Office of Leadership Education, Rady Faculty of Health Services; Associate Professor, Department of Pediatrics and Child Health, University of Manitoba.
Jamiu O. Busari, MBChB, MD, MHPE, PhD, CCPE, is Dean of HOH Academy at Dr. Horacio Oduber hospital in Aruba; Associate Professor of medical education and researcher at Maastricht University and founder of Jump18-Aruba Childhood Obesity prevention program.
1. Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach. 2010;32(8):631-7.
2. Tweed T, Maduro C, Güneș N, et al. Diversity matters: the other doctor within the Dutch academic healthcare system. BMJ Leader Published Online First: 27 September 2021.
3. Freeman BK, Landry A, Trevino R, et al. Understanding the leaky pipeline: perceived barriers to pursuing a career in medicine or dentistry among underrepresented-in- medicine undergraduate students. Acad Med 2016;91:987–93.
4. Jemal A. Critical Consciousness: A Critique and Critical Analysis of the Literature. Urban Rev. 2017;49(4):602-626.
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