As we move through the first iteration of the Social Pediatrics Curriculum Program, we have spent many hours thinking, observing, and having conversation with residents and faculty alike about their perceptions of providing care. Care that is compassionate. Care that is both equitable and inclusive. Person and family-centred care. Care that is customized for diverse populations. How to teach for culturally sensitive care. What to teach for social justice-oriented care. Whether reflexive care can be taught and nurtured. How to get faculty to prioritize care that thoughtfully considers the whole person within the context of their environment and the various systems, which impact them.
We have come to realize that multiple perceived barriers exist within the current structure of medical education and its culture that limit both the teaching and learning of social pediatrics. Even for those residents that identify a commitment to and understanding of social aspects of care, it becomes evident that most residents quickly learn to value the “medical expert” components of the curriculum and come to view social pediatrics curriculum as “time consuming” and “busy work”. The current focus on patient access and flow in academic teaching hospitals where the core of residency training often occurs, has been noted to result in more focused clinical assessments, an emphasis on managing acute medical issues, and less time for discussion about the social aspects of care despite their key role in patient outcomes (van den Heuvel et al. BMC Medical Education; 2017).
The other challenge we have come to know is the current approach to teaching social pediatrics positions the social determinants of health as “facts to be known” rather than as “structures to be challenged and changed.”
Incorporating topics such as poverty but not oppression. Gender identity but not homophobia. And highlighting various ethnic groups without talking about racism. This approach to delivery of education inadvertently risks perpetuating the same biases often assumed of our most vulnerable populations. Personal values, culture, and lived experience also have significant impact on the formulation of our perceptions and biases. These implicit biases bear impact on the relationships developed with patients and their families during their care experience. I suggest the current residency training process does not prepare future physician specialists well for the challenges of bringing their authentic curious selves into their practice of medicine. The residents that we spoke with described the need for both improved culture and training processes that nurtured opportunities for reflection and professional development without fear of reprisal. Other residents identified more guidance and positive role modeling from faculty was needed.
It became evident a need to work with an established culture to create change, while at the same time challenging the implicit bias embedded within that very culture.
Considering the emergent themes of reflective practice, I suggest this process requires critical re-structuring of residency training. Developing curricular efforts that contribute to self-awareness, reflection and ongoing professional development. To learn, appreciate and respect how different individuals can have very different perceptions and understanding of the same thing. And to imbed processes which support faculty development for skilled mentoring and reflective coaching for residents throughout their training.
Addressing both culture and personal biases hinder, in large part, on the establishment of trust. Trust between curriculum innovators, residents, faculty and the program. We all experience a sense of vulnerability in this relationship. Our successes can only be realized if we pay close attention to establishing and maintaining this trust as we challenge and recreate the future for medical education.
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