Teaching and Learning in Medicine最新文献

Uncertainty and disability are simultaneously well-studied and enigmatic conditions in medicine. Yet while uncertainty and disability have individually received significant attention, little mind has been paid to how they interact. Common assumptions and biases underscore the frequently negative view of both conditions. However, overemphasis on reducing and eliminating uncertainty has negatively impacted physicians beholden to a culture that venerates certainty. At the same time, medicine's focus on fixing and curing disability, which is founded on ableist practices and policies, has led to deleterious patient health outcomes. If what is required for equitable, person-centered care is a greater tolerance of uncertainty, then we might derive wider benefits from approaches with demonstrated efficacy in dismantling ableist logic. For this reason, we employ the social model of disability to formulate three interrelated strategies for reframing uncertainty as a source of possibility in clinical encounters and life more broadly. The first strategy entails reappraising mental models that have contributed to structural barriers. Applying Paul Han's framework for tolerance to pervasive sources of bias, we argue that reappraisal inhibits certainty preference from erasing the subjectivities that invigorate our collective wisdom and grant significance to our lived experiences. The second strategy involves reexamining ways of knowing that have controlled ways of being. By applying a critical lens to the labels and categories indispensable to contemporary knowledge systems, we illustrate how an ethics of uncertainty can help us realize the principles of epistemic justice. The third strategy involves replacing the "un-choosing of disability" as described by the disabled poet and activist Eli Clare with the reclaiming of uncertainty. This approach reveals how creating a medical culture that fosters meaning and purpose can positively influence the relational aspects of care. Collectively, these strategies form the foundation of a praxis necessary to foster tolerance of uncertainty and bodily variability throughout medicine. We conclude by demonstrating how leaning into the discomfort inherent to paradoxes can transform uncertainty from a limiting factor to a liberating force for epistemic justice.

Despite increased attention and advocacy around disability in academia, both health professions trainees and Disabled people seeking healthcare in the US continue to report shortcomings in the providers' preparedness to care effectively for Disabled patients. Some of these shortcomings have historical roots in flawed theories of disability and ableism, but even with advancements in Disability Studies and the adoption of the biopsychosocial model of disability, trainees continue to receive insufficient exposure to disability theory and Disabled people. When graduates become independent providers and clinical directors, their educational shortcomings persist, and Disabled patients pay the price in the form of universally worse healthcare outcomes. We focus this article on the need for improved training; in part, we offer a student response to the health equity policy recommendation from the National Council on Disability to require "…comprehensive disability clinical-care curricula in all US medical, nursing and other healthcare professional schools," a platform also reflected in the American Medical Association's Organizational Strategic Plan to Advance Health Equity. A group of medical students and educators at a large health institution in Philadelphia, PA, formed a working group inspired by an institutional review process around disability in their medical curriculum. Alongside a Disabled advocate and licensed clinical social worker (LCSW) in the same community, students imagined steps they would take to pursue a Disability Affirming Model of Medicine. We begin this article by reflecting on the progress made in academic and clinical medicine on the national level and at our institution, examining persistent failures in disability curricula in undergraduate medical education and discussing elements of wisdom gleaned from allied fields like social work. Our LCSW coauthor reflects on his experiences as a Disabled provider and as an educator within a medical field that remains largely inaccessible. Student coauthors consider their meaningful experiences with disability in educational and personal spheres, focusing on how learning from Disabled people like their coauthor has shaped their approach to disability in healthcare. Reflecting on these lessons and drawing on wisdom from their experience with curricular reform around Disability Studies, students conclude with recommendations for pedagogical redesign to facilitate comfort and proficiency in trainees' delivery of care to Disabled patients. We hope to galvanize efforts toward building a Disability Affirming Model of Medicine by calling upon peer advocates at every level of medical education, at home in the US and internationally.

Power dynamics and hierarchy are influential facets of the medical learning environment that are often experienced but seldom studied. One reason for this gap is the lack of sound instruments to measure perceived power distance in medicine. Accordingly, we developed and evaluated the Perceived Power Distance Scale (PPDS). Initial item development involved a literature search that identified a power distance orientation instrument (beliefs about power distance), which we adapted to measure perceived power distance (perceptions of power distance). We gathered item content validity evidence from a panel of seven international scholars of power and hierarchy, resulting in minor item revision. Next, a convenience sample of 312 US medical students completed a survey comprising PPDS (to establish internal validity through confirmatory factor analysis and reliability estimation); a locally adapted power distance measure (to establish convergent validity); and a psychological safety measure (to establish discriminant validity). The best-fitting model was a higher order 1 + 5 factor model for PPDS, and PPDS overall scale reliability was adequate at 0.81. The correlation between the PPDS and an independent measure of power distance was 0.60 (convergent validity) and the correlation of the PPDS with psychological safety was -0.54 (discriminant validity). The PPDS demonstrated adequate evidence of content, internal, convergent, and discriminant validity, along with appropriate reliability evidence to measure perceived power distance in US medical schools. The PPDS can be used as a tracking metric to improve learning environments within medical education in coordination with organizational development efforts.

This evaluation study investigated the extent to which a medical school curriculum fostered cognitive integration in learners. The Active-Learning, Competency-Based, Excellence-Driven (ACE) curriculum was designed to present basic science content through a clinical lens to support students' ability to make connections between clinically relevant symptoms using basic science mechanisms. We included the graduating classes of 2023-2025 from the University of Kansas School of Medicine (KUSOM) (N = 630) in this study. A structural equation model assessed the mediating role of developmental clinical skills on the relationship between foundational knowledge, as demonstrated by course summative exam performance, and an end-of-third-year clinical skills assessment. Using a theory-driven (cognitive integration) evaluation approach, we predicted that, if cognitive integration was achieved, foundational knowledge during the first two years of medical school would have a direct relationship to clinical skills and that developmental clinical skills would partially or fully mediate that relationship. We also assessed the mediating role of developmental clinical knowledge, as demonstrated by NBME Subject Exam performance, on the relationship between foundational knowledge and clinical knowledge (United States Medical Licensing Exam Step 2 Clinical Knowledge exam (USMLE Step 2 CK) scores. Foundational knowledge had a strong relationship with a comprehensive clinical skills assessment, which was fully mediated by developmental clinical skills. Foundational knowledge also had a strong relationship with USMLE Step 2 CK scores, which was fully mediated by developmental clinical knowledge. Students who demonstrated greater foundational knowledge tended to score higher on a comprehensive clinical skills assessment at the end of the third year. This suggests that foundational knowledge acquired in the first two years of an integrated curriculum is strongly related to clinical skills and clinical knowledge in the clerkship year. Although this is not a causal test, the structural relationships suggest the ACE curriculum was successful in promoting cognitive integration in students.

Despite growing commitments to disability inclusion, ableism remains entrenched in medical education. Too often, proposed solutions emphasize inclusion without addressing the structural forces that perpetuate exclusion. In this article, we seek to bridge this gap, drawing on Disability Justice and decolonisation to challenge the norms that define success against ableist standards. At the intersections of these theories, we illustrate how colonialism and capitalism operate to drive the systematic exclusion of disabled learners in medicine. Drawing on Jain's concept of the "capability imperative," we make these comparisons explicit as we interrogate the notion of competency in clinical assessment, specifically in Observed Structured Clinical Examinations (OSCEs). This lens challenges us to consider how colonial capitalist norms shape definitions of competence and how this affects what is valued (or devalued) in our assessment practices. Offering a series of reflexive questions to prompt collective inquiry, we invite readers to begin to re-imagine learning environments and challenge the ableist paradigms that influenced the curricula under which our healthcare leaders trained. We seek to understand: are efforts to include disabled learners predicated on simulations of work in understaffed and underfunded healthcare systems? If so, are we replicating systems that not only exclude disabled doctors but demand sacrifice in the name of conformity and minimising disruption to safeguard productivity? Finally, what does this tell us about the power structures at play when it comes to assessing competency in medical education?

Medical education's pursuit of excellence often inadvertently fosters a "hidden curriculum" of perfectionism and shame. This culture can transform adaptive striving into maladaptive perfectionism, where a fear of failure leads learners to view mistakes not as growth opportunities but as evidence of moral failings and personal inadequacy. When errors inevitably occur, the potential result is shame or an identity-focused belief that "I am bad." The resulting isolation and self-doubt potentially can lead to imposter syndrome, burnout, and depression. This paper explores the critical role of shame-informed mentorship, an approach that recognizes how shame influences learner behavior and development. By responding with intentional strategies that preserve dignity, mentors can mitigate shame's potential impact and transform it into a catalyst for professional growth. We argue that by helping learners distinguish between corrosive shame ("I am the problem") and productive guilt ("I did something wrong"), mentors can facilitate behavioral change without damaging the learner's core identity. The paper offers practical, evidence-based strategies organized into three themes: Recognition-identifying "shame primers" such as perfectionistic histories and "shame triggers" like public questioning; Navigation-using validation, self-compassion, and the practice of "failing forward" to process active shame events; Cultivation-building long-term resilience through intellectual humility and the normalization of shared narratives. Collectively, these strategies provide a framework for intentionally building psychological safety and normalizing mistakes. By equipping mentors with tools to recognize and respond to shame, and by creating a culture that prioritizes formative feedback and a growth mindset, mentors can help transform shame from a destructive force into a catalyst for professional identity development and sustainable practice.

Engagement with interprofessional education (IPE) is essential to prepare health professions students for collaborative practice, yet the behavioral determinants shaping students' active participation remain insufficiently understood. This review conceptualizes engagement as a proximal behavioral construct reflecting students' cognitive, affective, and behavioral involvement in IPE activities. We employed the Theoretical Domains Framework (TDF) as it synthesizes behavior-change constructs into modifiable domains, enabling systematic identification of determinants and theory-informed targets for intervention. We searched six databases (PubMed^®, Medline^®, EMBASE^®, CINAHL^®, ProQuest^®, and ERIC) for articles published between January 2010 and October 2024, with updates conducted to January 2026. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Crowe Critical Appraisal Tool. We synthesized reported enablers and barriers influencing student engagement using deductive content analysis and mapped them to TDF domains. We included 30 studies. We identified determinants of student engagement with IPE across 12 of the 14 TDF domains. The most commonly identified enabler was Social/Professional Role and Identity, particularly through role clarification, understanding of professional responsibilities, and recognition of complementary contributions within teams. Other frequently represented enablers included Environmental Context and Resources (e.g., structured clinical exposure, immersive placements, simulation, and repeated opportunities for interaction), Social Influences (e.g., facilitator support, peer relatedness, mentoring, and encouragement), Knowledge, Skills, Beliefs about Consequences, and Beliefs about Capabilities. We mapped barriers to nine TDF domains, with Social Influences emerging as the most common barrier, particularly through hierarchy, dominance of some professional groups, isolation, and lack of authority to speak up. Other common barriers included Environmental Context and Resources (e.g., limited time, scheduling conflicts, short placement duration, and workload pressures), Emotions (e.g., anxiety, defensiveness, and embarrassment), Knowledge (e.g., unclear expectations and limited understanding of other professional roles), and Beliefs about Capabilities (e.g., low self-confidence in contributing to interprofessional discussions). Student engagement with IPE is shaped by modifiable cognitive, affective, and contextual determinants. Mapping these influences through the TDF clarifies the behavioral mechanisms underpinning engagement and identifies theory-informed targets for the design and delivery of IPE interventions.

Purpose: International medical graduates (IMGs) have long sustained the US healthcare system. In the US, 25% of practicing physicians are IMGs, who are pivotal for delivering primary and preventive care and for tending to first-generation immigrants. Despite their contributions, studies primarily have focused on individual challenges and difficulties of IMGs. In contrast, structural barriers-and their impact on IMGs' private lives and emotional wellbeing-are rarely discussed. Using the example of Asian IMGs in the US, we explored structural barriers that complicate everyday thriving, including family wellbeing, work conditions, and emotional life. Method: We conducted a constructivist, qualitative interview study with 20 IMG physicians (60% female) in 2023. We purposefully sampled across multiple specialties, clinical settings, and geographic areas. The average time serving as an attending was 11.8 years. We recorded and transcribed semi-structured interviews, which lasted 45-60 minutes. With attention to IMGs' positionality, we applied reflexive thematic analysis and Burgess-Proctor's strategies for engaging with and empowering participants. We also drew on Ahmed's theory of the politics of emotions to inform our interpretation. Results: IMGs described interconnected structural barriers rooted in the US visa system, including financial hardship, prolonged family separation, and sponsorship-dependent career precarity. Beyond these constraints, participants also encountered institutional selection bias and professional gatekeeping, including an invisible ceiling, tokenization, and limited recognition of IMG status within broader diversity discourse. While expressing gratitude for US career opportunities, participants reported a significant emotional toll characterized by guilt and shame tied to outsider positioning and pressures to justify their legitimacy in US training. Discussion: Structural barriers have a profound impact on IMGs' relational and emotional lives. What might appear as a personal hardship-such as family separation-is in fact a consequence of structurally imposed constraints. Participants pointed to concrete areas where institutional practices could change, including formalized mentorship structures, stronger institutional accountability, more explicit inclusion practices, and policy advocacy. Addressing these inequities will require institutional engagement, with implications for sustaining the US physician workforce.

Medical students increasingly rely on third-party resources, or study tools developed outside of formal medical education institutions, to study for the US Medical Licensing Exams (USMLE). One such third-party resource is Anki, an online flashcard platform, and the AnKing, a premade deck created by a group of medical students. While prior scholarship has begun to analyze the content and benefits of such third-party resources, few have considered how not only the content but also the design and usage patterns of such resources may perpetuate medical knowledge that is harmful to patients. Trained in both medicine and history as an MD/PhD student, the author considers how expertise from the social sciences can inform our analysis of the process by which historical medical knowledge on race, health, and disease is developed, maintained through historical change, and passed down to current medical students. Sociological methods in Science and Technology Studies informed the analysis of Anki as a political technology, where social values are embedded in its design, typical use by students, and repair mechanisms, or how the technology is maintained and updated. The author accompanies her experience studying with AnKing from 2020 to 2022 with a systematic content analysis of AnKing's training videos and social media posts (March 2025-February 2026) and of the race-based medical content in the AnKing deck (Update #14, March 2025). Historical literature on race-based medicine informed analysis of emerging themes in the deck. Anki's design with a distinct question-and-answer format and its embedded values of speed and volume in usage patterns help form implicit associations, including between race and disease risk. Its repair mechanism via mass collaboration and self-reference to other third-party resources contribute to the perpetuation of historical concepts of race-based medicine. In AnKing, 0.5% of flashcards (202/42,629) contained references to differing diagnosis and treatment patterns among racial groups. Three major definitions of race appeared: racial groups as defined by differing prevalence of disease, race as a shortcut for genetic heritability, and race as a risk factor for disease. AnKing defines clearly demarcated biological racial categories as an individual patient characteristic that increases risk of disease, lacking the historical and social context which reveal the structural role of racism in health. By considering one popular third-party resource through the lens of the history and sociology of medicine, the author demonstrates how insights from the social sciences inform how medical knowledge develops, transforms over time, and continues to perpetuate within the contemporary educational environment.

When we began our first year of medical school at a US MD-granting institution, we were elected as head Course Representatives (Course Reps) in a longstanding, Feedback-Driven representation model. In this reflection, we explore how serving in this role shaped students' engagement and sense of belonging in our institution through the lived experience of representation. Drawing on Student Engagement Theory as an organizing lens, we analyze our experience and those of our peers across behavioral, emotional, and cognitive dimensions of engagement. Behaviorally, engagement was reinforced when student feedback led to visible and timely changes, demonstrating the legitimacy of the student voice and validating institutional responsiveness. Emotionally, representation functioned as a belonging cue as peers reported greater trust and psychological safety when concerns were voiced by fellow students rather than faculty. Cognitively, opacity (what students described as the "black box" of decision-making) provoked curiosity about institutional constraints and trade-offs, fostering systems-level thinking about curriculum design. Equally meaningful were the lessons we learned about ourselves. Serving as Course Reps required emotional labor we had not anticipated, including navigating the weight of peers' frustrations and advocating for diverse viewpoints we personally did not hold. Through this work, we discovered that representation can transform the representatives as much as those they represent, deepening our own sense of belonging, purpose, and agency. Our understanding evolved through sustained dialogue with classmates and our faculty mentor. By situating our lived experiences within the literature on student governance and belonging, we argue that Feedback-Driven representation systems do not just fix student concerns: they shape how students perceive their legitimacy and connection to their institution. Learners are important stakeholders whose insights and engagement meaningfully shape their educational experiences. When students are invited into authentic collaboration with faculty, they gain a sense of ownership in their education. For us, that sense of agency and belonging has been one of the most enduring lessons of medical school.