Unravelling epistemic injustice in medical education: The case of the underperforming learner.
Journal
Medical education
ISSN: 1365-2923
Titre abrégé: Med Educ
Pays: England
ID NLM: 7605655
Informations de publication
Date de publication:
27 Apr 2024
27 Apr 2024
Historique:
revised:
22
03
2024
received:
12
01
2024
accepted:
29
03
2024
medline:
27
4
2024
pubmed:
27
4
2024
entrez:
27
4
2024
Statut:
aheadofprint
Résumé
Epistemic injustice refers to a wrong done to someone in their capacity as a knower. While philosophers have detailed the pervasiveness of this issue within healthcare, it is only beginning to be discussed by medical educators. The purpose of this article is to expand the field's understanding of this concept and to demonstrate how it can be used to reframe complex problems in medical education. After outlining the basic features of epistemic injustice, we clarify its intended (and unintended) meaning and detail what is required for a perceived harm to be named an epistemic injustice. Using an example from our own work on introversion in undergraduate medical education, we illustrate what epistemic injustice might look like from the perspectives of both educators and students and show how the concept can reorient our perspective on academic underperformance. Epistemic injustice results from two things: (1) social power dynamics that give some individuals control over others, and (2) identity prejudice that is associated with discriminatory stereotypes. This can lead to one, or both, forms of epistemic injustice: testimonial and hermeneutical. Our worked example demonstrates how medical educators can be unaware of when and how epistemic injustice is happening, yet the effects on students' well-being and sense of selves can be profound. Thinking about academic underperformance with epistemic injustice in mind can reveal an emphasis within current educational practices on diagnosing learning deficiencies, to the detriment of holistically representing its socially constructed and structural nature. This article builds upon recent calls to recognise epistemic injustice in medical education by clarifying its terminology and intended use and providing in-depth application and analysis to a particular case: underperformance and the introverted medical student. Equipped with a more sophisticated understanding of the term, medical educators may be able to re-conceptualise long-standing issues including, but also beyond, underperformance.
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.
Références
Brown MEL, Veen M, Finn GM. Applied Philosophy for Health Professions Education: a Journey Towards Mutual Understanding. Springer; 2022:380. doi:10.1007/978‐981‐19‐1512‐3
Percival CS, Maggio LA, Wyatt TR, Martin PC. ‘The program director’s word … it's stronger than the word of God’: epistemic injustice revealed through narratives of remediated graduate medical education residents. Med Educ. 2023. doi:10.1111/medu.15295
Percival CS, Martin PC, Maggio LA, Wyatt TR. When I say … epistemic injustice. Med Educ. 2024;58(5):497‐498. doi:10.1111/medu.15300
Fricker M. Epistemic Injustice: Power and the Ethics of Knowing. Oxford University Press; 2007:208. doi:10.1093/acprof:oso/9780198237907.001.0001
Kidd IJ, Carel H. Epistemic injustice and illness. J Appl Philos. 2017;34(2):172‐190. doi:10.1111/japp.12172
Steup M. Epistemology. Stanford Encyclopedia of Philosophy; 2020 Apr 11. Available from: https://plato.stanford.edu/entries/epistemology/
Blease C, Carel H, Geraghty K. Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome. J Med Ethics. 2016;43(8):549‐557. doi:10.1136/medethics‐2016‐103691
Carel H, Kidd IJ. Epistemic injustice in healthcare: a philosophical analysis. Med Health Care Philos. 2014;17(4):529‐540. doi:10.1007/s11019‐014‐9560‐2
George T. Hermeneutics. Stanford Encyclopedia of Philosophy 2020 Dec 9. Available from: https://plato.stanford.edu/entries/hermeneutics/
Dunne G. Epistemic injustice in education. Educ Philos Theory. 2023;55(3):285‐289. doi:10.1080/00131857.2022.2139238
Kidd IJ, Medina J, Pohlhaus G. The Routledge Handbook of Epistemic Injustice. Routledge; 2017:438. doi:10.4324/9781315212043
Kidd IJ, Spencer L, Carel H. Epistemic injustice in psychiatric research and practice. Philos Psychol. 2022;1‐29. doi:10.1080/09515089.2022.2156333
Freeman L. Confronting diminished epistemic privilege and epistemic injustice in pregnancy by challenging a “panoptics of the womb”. J Med Philos. 2015;40(1):44‐68. doi:10.1093/jmp/jhu046
Bullock CG. Experiencing ‘epistemic injustice’ within transgender healthcare. Sex Gender Policy. 2023;6(1):47‐50. doi:10.1002/sgp2.12059
Leckey R, Schmieder‐Gropen R, Nnebe C, Clouthier M. Indigenous parents and child welfare: mistrust, epistemic injustice, and training. Soc Leg Stud. 2022;31(4):559‐579. doi:10.1177/09646639211041476
Crichton P, Carel H, Kidd IJ. Epistemic injustice in psychiatry. Br J Psychiatry Bull. 2017;41(2):65‐70. doi:10.1192/pb.bp.115.050682
Sanati A, Kyratsous M. Epistemic injustice in assessment of delusions: epistemic injustice in delusions. J Eval Clin Pract. 2015;21(3):479‐485. doi:10.1111/jep.12347
Maggio LA, Costello JA, Ninkov AB, Frank JR, Artino AR. The voices of medical education scholarship: describing the published landscape. Med Educ. 2022;57(3):280‐289. doi:10.1111/medu.14959
Blalock AE, Leal DR. Redressing injustices: how women students enact agency in undergraduate medical education. Adv Health Sci Educ. 2023;28(4):741‐758. doi:10.1007/s10459‐022‐10183‐x
Bynum WE, Teunissen P, Varpio L. In the “shadow of shame”: a phenomenological exploration of the nature of shame experiences in medical students. Acad Med. 2021;96(11):S23‐S30. doi:10.1097/ACM.0000000000004261
Bynum WE IV, Sukhera J. Perfectionism, power, and process: what we must address to dismantle mental health stigma in medical education. Acad Med. 2021;96(5):621‐623. doi:10.1097/ACM.0000000000004008
Hankir AK, Northall A, Zaman R. Stigma and mental health challenges in medical students. BMJ Case Rep. 2014;2014(sep02 1):bcr2014205226. doi:10.1136/bcr‐2014‐205226
de Oliveira E, Dantas RG, Amaral GA, Giaxa RRB, Teixeira de Góis AF. Experiences of disabled students in undergraduate medical education. Med Teach. 2022;44(3):294‐299. doi:10.1080/0142159X.2021.1985098
Butler K, Yak A, Veltman A. “Progress in medicine is slower to happen”: qualitative insights into how trans and gender nonconforming medical students navigate cisnormative medical cultures at Canadian training programs. Acad Med. 2019;94(11):1757‐1765. doi:10.1097/ACM.0000000000002933
Jacobs C, Van Schalkwyk S. What knowledge matters in health professions education? Teach High Educ. 2022;27(8):1068‐1083. doi:10.1080/13562517.2022.2111207
Kotzee B. Education and epistemic injustice. In: Kidd IJ, Medina J, Pohlaus GJ, eds. The Routledge Handbook of Epistemic Injustice. Routledge; 2017:324‐335. doi:10.4324/9781315212043‐32
Hodges BD, Lingard L. The Question of Competence. Cornell University Press; 2012:240.
Ross S, Pirraglia C, Aquilina AM, Zulla R. Effective competency‐based medical education requires learning environments that promote a mastery goal orientation: a narrative review. Med Teach. 2022;44(5):527‐534. doi:10.1080/0142159X.2021.2004307
Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS: better standards, better physicians, better care. [Internet]. 2015 [cited 2022 Dec 1]. Available from: https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
Cleland J, Leggett H, Sandars J, Costa MJ, Patel R, Moffat M. The remediation challenge: theoretical and methodological insights from a systematic review. Med Educ. 2013;47(3):242‐251. doi:10.1111/medu.12052
Hauer KE, Ciccone A, Henzel TR, et al. Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature. Acad Med. 2009;84(12):1822‐1832. doi:10.1097/ACM.0b013e3181bf3170
Brenner AM, Mathai S, Jain S, Mohl PC. Can we predict “problem residents”? Acad Med. 2010;85(7):1147‐1151. doi:10.1097/ACM.0b013e3181e1a85d
Steinert Y. The “problem” learner: whose problem is it? AMEE Guide No. 76. Med Teach. 2013;35(4):1035‐1045. doi:10.3109/0142159X.2013.774082
Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000;284(9):1099‐1104. doi:10.1001/jama.284.9.1099
Ahmady S, Khajeali N, Sharifi F, Mirmoghtadaei ZS. Causes of academic failure in preclinical medical education: a systematic review. J Adv Med Educ Prof. 2019;7(2):74‐85. doi:10.30476/JAMP.2019.44711
Kalet A, Chou CL. Remediation in Medical Education: a Midcourse Correction. 2nd ed. Springer; 2023:330. doi:10.1007/978‐3‐031‐32404‐8
Parker‐Newlyn L, Dore KL, Mansfield K. Predicting students who struggle: using admissions data to identify factors associated with impeded progress in medical school [Conference presentation]. Admissions Summit; 2021 June 7; Toronto, Canada. Available from: https://scholars.uow.edu.au/display/publicationse319767
Bourgeois‐Law G, Teunissen PW, Regehr G. Remediation in practicing physicians: current and alternative conceptualizations. Acad Med. 2018;93(11):1638‐1644. doi:10.1097/ACM.0000000000002266
Weis L. Identity formation and the processes of ‘othering’: unraveling sexual threads. Educ Foundations. 1995;9(1):17‐33.
Jensen SQ. Othering, identity formation and agency. Qs. 2011;2(2):63‐78. doi:10.7146/qs.v2i2.5510
Bourgeois‐Law G, Teunissen PW, Varpio L, Regehr G. Attitudes towards physicians requiring remediation: one‐of‐us or not‐like‐us? Acad Med. 2019;94(11):S36‐S41. doi:10.1097/ACM.0000000000002896
Gourlay L. Student engagement and the tyranny of participation. Teach High Educ. 2015;20(4):402‐411. doi:10.1080/13562517.2015.1020784
Macfarlane B. Student performativity in higher education: converting learning as a private space into a public performance. High Educ Res Dev. 2015;34(2):338‐350. doi:10.1080/07294360.2014.956697
Macfarlane B. The performative turn in the assessment of student learning: a rights perspective. Teach High Educ. 2016;21(7):839‐853. doi:10.1080/13562517.2016.1183623
Boileau E, St‐Onge C, Audétat M‐C. Is there a way for clinical teachers to assist struggling learners? A synthetic review of the literature. Adv Med Educ Pract. 2017;8:89‐97. doi:10.2147/AMEP.S123410
Davidson B, Gillies RA, Pelletier AL. Introversion and medical student education: challenges for both students and educators. Teach Learn Med. 2015;27(1):99‐104. doi:10.1080/10401334.2014.979183
Luong V, Shields C, Petrie A, Neumann K. Does personality matter? Perceptions and experiences of introverts and extraverts as general surgeons. Teach Learn Med. 2022;34(3):255‐265. doi:10.1080/10401334.2021.1922284
Mason R. Two kinds of unknowing. Hypatia. 2011;26(2):294‐307. doi:10.1111/j.1527‐2001.2011.01175.x
Bell A, Cavanagh A, Connelly CE, Walsh A, Vanstone M. Why do few medical students report their experiences of mistreatment to administration? Med Educ. 2021;55(4):462‐470. doi:10.1111/medu.14395
Rudland JR, Tweed MJ, Jaye C, Wilkinson TJ. Medical student learner neglect in the clinical learning environment: applying Glaser's theoretical model. Med Educ. 2021;55(4):471‐477. doi:10.1111/medu.14424
Regehr G. It's NOT rocket science: rethinking our metaphors for research in health professions education. Med Educ. 2010;44(1):31‐39. doi:10.1111/j.1365‐2923.2009.03418.x
Veen M, Cianciolo AT. Problems no one looked for: philosophical expeditions into medical education. Teach Learn Med. 2020;32(3):337‐344. doi:10.1080/10401334.2020.1748634
Popowicz DM. “Doctor knows best”: on the epistemic authority of the medical practitioner. Phila Med. 2021;2(2):1‐23. doi:10.5195/pom.2021.49
Valles SA. Why race and ethnicity are not like other risk factors. Phila Med. 2021;2(1):1‐8. doi:10.5195/pom.2021.52
Govender L, Church HR. When I say … ‘non‐clinical practice’. Med Educ. 2024;58(2):183‐184. doi:10.1111/medu.15177