Centering Criticality in Medical Education Research
A Synthesis of the 2022 Rime Papers
Bibliographic Data
In the 2021 RIME forward, the RIME committee’s current, past, and future chairs posed the following question to the medical education research community: “What steps have we taken to advance scholarship that dismantles systems of oppression and brings marginalized voices to the forefront?” 1 The chairs raised this question because they were concerned that medical education research is steeped in traditions that have historically excluded marginalized voices at the level of both researcher and participant. In their effort to direct our community to the importance of this topic, in the 2021 RIME forward, Park et al 1 challenged the medical education research community to “question traditional research practices.” They suggested that we embrace new approaches that seek to disrupt the status quo in social science research and begin to reimagine centering the voices and experiences of marginalized individuals and groups. As a result of this call to action, many of the authors of the papers accepted in the 2022 RIME supplement incorporated a critical stance into their research. Unlike traditional social science research, which aims to merely capture the world as it works, critical research views knowledge as having potential to emancipate marginalized individuals by questioning underlying assumptions embedded in the research process. To do this, researchers must inscribe power relations within the problem of research by giving attention to how various forms of power operate within our systems to replicate the status quo. 2 This can be accomplished by “shaking up habits, ways of acting and thinking, [and] dispelling commonplace beliefs.” 3(p11,12) Or, in what may be the most eloquent description written of critical research, researchers using a critical stance seek “to create knowledge with the potential to wreak havoc” 4(p76) and create transformational change. Critical research is an approach to research studies that interrogates, exposes, and challenges assumptions about how power and privilege function to obscure structural inequality. 5 A critical approach asserts that research can never be nonpartisan, and therefore researchers must work to expose hidden ideological assumptions. Therefore, critical research, unlike more familiar forms (i.e., positivist and postpositivist research), engages with larger social, historical, and ideological forces that influence and shape individuals, while also providing marginalized communities with the tools they need to resist the systems that shape them. This approach is particularly helpful when ideas on a topic have become fossilized, or do not explain the experiences of marginalized individuals and groups. It can also be useful to reinscribe how larger structures and processes influence and shape the lives of those most vulnerable by disrupting the societal fabric often taken for granted, and then planting seeds of transformation. As critical research becomes more mainstream, there are many tactics to conducting a critical approach to research, and the 2022 RIME papers demonstrate some of these ways. In an effort to continuously educate our medical education research community on how to conduct critical research, what follows is a brief overview of each of the articles, drawing attention to where and how the authors approached their work from a critical perspective. In examining the accepted 2022 RIME papers, some of the authors incorporated criticality at the level of research questions, others at the level of analysis, and still others in the overall framing of the study. Papers that did not take a critical approach set up topics to create opportunities for untapped critical research. As such, the 2022 RIME papers provide a corpus of literature to argue for how criticality can be used at different levels of the research process. Therefore, as newest members of the RIME committee, we have narrated the papers in terms where authors incorporated a critical stance into their work, or where they could have undertaken a critical study. We hope to not only provide the medical education community with a structured approach to evaluate the accepted 2022 RIME papers but also a resource to move their own work into a more critical perspective. Examining the literature and conducting knowledge syntheses can be accomplished either by collating and synthesizing a literature base for what is published on a particular topic or by investigating not only what is present in the literature but also what is not there, yet should be. In this latter form, Paton et al 6 call this kind of research absence research because by investigating what is not present on a particular topic, researchers can raise larger questions about why information on a particular topic has not been investigated, who benefits, and the consequences for not having this information available. Four author groups in the 2022 RIME supplement took a critical view of the literature, interrogating it for the ways it silences and erases certain perspectives in favor of others. These papers included Mount et al’s 7 critical review, which highlighted the way professional identity formation (PIF) is taught. The review identified the dominance of individualistic approaches to PIF and called for more interventions emphasizing the social aspects of identity formation. The authors called for focus on intersectional experience of PIF to examine how the interactions between gender, race, and other identities influence individual’s professional identity. They recognized how other identities influence the ways in which one conceptualizes being a professional and carries out their roles. To take it one step further, researchers could explore how larger social, historical, and cultural factors impact PIF, and even begin to critically question what it means to be a professional, and where this line is drawn. Han et al 8 conducted a descriptive quantitative study to examine current trends in methodologies and rigor in health professions education (HPE). Their work found that HPE primarily used quantitative methodologies, and that there was a lack of “subjectivist epistemologies and philosophical frameworks highlighting critical inquiry, feminism, and postmodernism.” This is an important paper because it raises larger questions about how knowledge is created in our profession, what methodologies are leading these efforts, and the potential consequences in staying with the current trends. Yet, embracing new ways of doing research is challenging, as evidenced by the fact that the authors drew upon a positivist epistemology in their study. It would have been interesting to see whether a critical approach in this study would have resulted in a different presentation of the results and discussion of those papers included. Watsjold et al 9 critically reviewed the foundational and current literature on clinical reasoning from the field of ecological psychology to explore its concepts and use in HPE. They argue that clinical reasoning could be reframed as a phenomenon that emerges out of the clinician’s effectivities and facilitators in the clinical environment, thus challenging the way clinical reasoning is currently positioned as an activity that occurs within the individual. This paper has important implications for workplace assessments including EPAs 10 and changing the way clinical reasoning is assessed. Although not overtly critical, this paper challenges the status quo on an important, almost sacred topic in medical education; the idea that clinical reasoning is an individual act. To take the level of criticality to the next level, future research may want to investigate how clinicians’ clinical reasoning efforts either ignore or conjure larger historical, social, cultural, and structural elements, especially as they relate to addressing health care in marginalized and oppressed individuals. Moreover, how a clinician’s social location may provide greater access to this understanding in ways that are incommensurate to their nonmarginalized peers. Petrey et al 11 conducted a scoping review in which authors investigated how medical education scholarship portrays transgender and nonbinary (TGNB) identities in patient simulation. This paper pushes medical education to think about the ways to train medical students on TGNB health, given that this population often experiences marginalization in clinical settings. Astutely, this paper raises questions about how inauthentic portrayal of TGNB patients might create harmful clinical practices. The implications for this work are that TGNB patients need to be cast authentically, rather than asking cisgender individuals to play this role. Researchers interested in building on this study might consider following students longitudinally into their clerkships to see how framings and perspectives toward TGNB patients being developed in simulation are later expressed in clinical settings. Researchers can also transform their work by approaching the data collection and analytical processes from a critical perspective. This entails asking critical questions about a topic, using a critical theory (e.g., critical race theory (CRT), 12 decolonial theory, 13 etc.) to frame a study, or applying a critical analytical lens at both the analytical and interpretive stages. Of the papers selected for the RIME supplement this year, 3 papers used criticality to frame data collection and/or analyses. These papers remind us that as researchers, we design studies in ways that draw attention to issues of power or ignore its influence in the research process. Hanson et al 14 investigated why racial/ethnic disparities exist in clinical clerkship grading that seem to fall along racial lines. Using CRT as a conceptual and analytical framework, the authors found that grading disparities are a result of complex issues that will not resolve with simple solutions, such as focusing on faculty antibias training, or simply addressing issues of student assessment and grading. Rather, this study points to larger systemic and structural issues that infiltrate the learning environment, making the system of training inequitable for racially diverse trainees, and medical educators a means for perpetuating the system. Fluet et al 15 interviewed standardized patients’ (SPs’) perspectives on bias and how they view their role in mitigating/perpetuating bias in simulation. The results showed that SPs located the least amount of bias in the simulation from students, who were careful in depicting their role as physician while being evaluated. Their study raises bigger questions about where bias is expressed in simulation and how “being watched” might influence its presence. This finding has implications for racially minoritized physicians who are frequently the only Black and/or brown individual in the room. Additionally, when SPs identified bias in the simulated environment, it was not their “place to say something because of the structure of the learning,” which calls for further examination of the underlying hierarchy of SPs in the training of the next generation of physicians. Boyd et al 16 conducted an experimental study to investigate the impact of dialogic learning on critically reflective practice. The authors created a pediatric patient case that was intended to prompt critical reflection and critical disability-related constructs and was analyzed for how dialogic prompts encouraged learners to question societal assumptions, discourses, and power relations. The analysis found that dialogic learning informs not only ways of seeing practice but also critically reflective ways of doing practice. Their work has larger implications for how HPE might better incorporate training opportunities that prompt learners to question physicians’ role in perpetuating ideological bias toward ableism and positioning disability as a fixed state. From a critical perspective, this paper, and studies like this, are incredibly important in that they infuse the curriculum with various forms of critical pedagogy and push medical learners to think about moving beyond merely working within the health care system. Students need to question their field for the ways it brings harm and begin to understand their role in resisting the system to support those who are vulnerable within it. In some cases, criticality isn’t included in the review of the literature or in the data collection or analytical phases, rather it comes in the discussion and implications that come from this work. In such cases, the study may not have been designed to disrupt the status quo, but in the process of analyzing the findings, there are powerful implications for what was found. McClintock et al 17 incorporated critical theory in the theoretical framing to highlight the role of hierarchy and power in promoting or diminishing psychological safety in clinical learning, and made a strong push for what this finding means for clinical environments in the discussion and implications section. The researchers conducted a multicenter interview study, in which they interviewed trainees about their experiences with psychological safety. They were able to show how clinical teachers’ leadership behaviors can create, destroy, and rescue psychological safety among trainees, thus implicating how clinical leaders contribute to unsafe environments. This paper takes an important critical perspective on the learning environment in that demonstrates how hierarchy and power express itself in the student–teacher relationship, and the effect that this has on trainees. This work has implications for thinking about how medical students might resist and/or support clinical educators’ efforts in creating psychological safety, so that the learning environment is repositioned as a co-construction with students, rather than a fixed context that students step into. Of course, not all research can be critical, nor should it be. Medical education needs researchers to lay down foundational studies to move a topic of conversation forward as a precursor for conducting critical work. In this year’s 2022 RIME supplement, there were 3 papers selected for their own merits that lay a solid foundation for future researchers wishing to expand this work with a critical lens. Ryan et al 18 conducted a quantitative content analysis of textual data around medical school’s educational program objectives (EPOs). They argued that EPOs, which form the backbone of integrated curricular design, are an important source of information to understand schools and their assessment methods. They found that most schools use Accreditation Council for Graduate Medical Education (ACGME)’s competency-based medical education (CBME) outcomes, and most do so around Liaison Committee on Medical Education (LCME) visits. This paper lays a foundation for future researchers to interrogate the sanctity of CBME and the responsibility of ACGME to include competencies such as antiracism, oppression, and health equity. Additionally, researchers might also raise larger questions in their work around the idea that in medical education, LCME has unilateral power over medical schools and the way it designs its programs. Such asymmetrical power differences can only bring harm to those who are marginalized in the system, as such relationships inevitably deploy norms and norming processes that work toward standardization and benchmarking outcomes that favor the majority voices. Sebok-Syer et al 19 investigated whether electronic health record (EHR) report cards help residents understand and interpret their clinical performance metrics. They demonstrate that this report card can be valuable source of education data providing self-reflection and actionable changes to practice, as well as helping faculty show underperforming residents’ data about their clinical performance. Future research might consider examining outcomes from the perspective of whether EHR data was useful for all learners or certain learners who don’t have access to dominant discourses and framings typically found in medical education training. A future study might further investigate how hierarchy impacts the kinds of coaching and feedback residents receive, and how structural factors impact what is included in the EHR and therefore able to be commented upon in these coaching sessions. Cheung et al 20 focused on the discontinuation of Step 2 clinical skills, which has prompted med schools to prioritize robust local assessments, including SP notes. The authors looked at the scores of those in the bottom quintile to see how the nontechnical raters scored them in comparison with the holistic faculty global scores for a subset of students. To take a critical stance, future research might interrogate the underlying assumption that clinician grading is the gold standard and the effort being taken to save clinical faculty’s time. This kind of a study would then question the fact that there is a long history within medicine that privileges clinical faculty members’ time above others and the consequences of this assertion to create healthy work environments. Cimino et al 21 conducted a critical narrative review that examined the literature for the roles and experiences faculty take on in interprofessional education. Cimino et al showed that these roles and struggles are complex and that faculty are not always equipped to handle their positions. Thus, their study draws attention to the need to support faculty in their roles. As a point of note, the methodology used in this paper (critical narrative review) uses the term “critical” to mean that the review is critical of the established knowledge in an area of interest. The term “critical” when used in reference to critical methodologies is best described as questioning or drawing attention to harmful power relations. 22,23 Future research might pursue this latter angle and study how power is infused with decision making around selecting and hiring HPE faculty into the profession, which emphasizes the importance of being able to perform well as an individual, and then expecting faculty to work collaboratively. In this way, researchers could consider interrogating medical education’s framing of an ideal worker 24 and how it interfaces within HPE. We frame our examination of the 2022 RIME papers by drawing attention to where and how the authors approached their work from a critical perspective. In our description of these impactful papers, we consider whether each paper incorporated criticality at the level of research questions, analysis, or overall framing; discussion of the study; or whether the paper set up opportunities for future critical research. In doing so, we have demonstrated how a critical perspective may be leveraged at multiple stages of the research process. In this year’s 2022 RIME overview, we provide medical education researchers with a summary of the myriad ways critical research can be integrated into the research process, regardless of the topic being studied. Additionally, we attempted to provide our community with a guideline to evaluate whether criticality has been incorporated into the various stages of the research process, including a critical approach in the review of the literature, asking critical questions to inform data collection and analysis, and whether the discussion and implications challenge the status quo. Armed with this information, we look forward to the community’s continued efforts toward “wreaking havoc” in medical education and creating transformational change. The authors would like to acknowledge all of the outstanding work put forth by the RIME authors, the RIME committee for the opportunity to comment on these papers, and the cochairs for their ongoing support
Hard rime · Oppression · Political science · Politics · Public relations · Scholarship · Social science · Sociology · Status quo · Empathy and Medical Education · Ethics in medical practice · Innovations in Medical Education · Law · Psychology
Synthesising qualitative and quantitative evidence
A typology of reviews
Facilitating Residents’ Understanding of Electronic Health Record Report Card Data Using Faculty Feedback and Coaching
Rime Foreword
Racial/Ethnic Disparities in Clerkship Grading
Standardized Patients’ Perspectives on Bias in Student Encounters
Clinician Teacher as Leader
Optimizing Clinical Reasoning Assessments With Analytic and Holistic Ratings
Competency-Based Frameworks in Medical School Education Programs
On the validity of summative entrustment decisions
On the Coloniality of Being
| Unique citing works | 4 |
|---|---|
| Citations per year | 1 |
| Citation span | 2022 - 2025 (4) |
| Citation velocity | recent |
| Highly cited | No |
| Citation types | Neutral: 4 |