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Introduction The arts and humanities have transformative potential for medical education. Realizing this potential requires an understanding of what arts and humanities teaching is and what it aims to do. A 2016 review of exclusively quantitative studies mapped three discursive positions (art as intrinsic to, additive to or curative for medicine) and three epistemic functions (art for mastering skills, perspective taking, and personal growth and activism). A more inclusive sample might offer new insights into the position and function of arts and humanities teaching in medical education. Methods Informed by this 2016 framework, we conducted discursive and conceptual analyses of 769 citations from a database created in a recent scoping review. We also analyzed the 15 stakeholder interviews from this review for recurring themes. These three analyses were iteratively compared and combined to produce a model representing the complex relationship among discursive functions and learning domains. Results The literature largely positioned arts and humanities as additive to medicine and focused on the functions of mastering skills and perspective taking. Stakeholders emphasized the intrinsic value of arts and humanities and advocated their utility for social critique and change. We offer a refined theory of practice—the Prism Model of four functions (mastering skills, perspective taking, personal insight and social advocacy)—to support more strategic use of arts and humanities in medical education across all learning domains. Discussion The Prism Model encourages greater pedagogical flexibility and critical reflection in arts and humanities teaching, offering a foundation for achieving its transformative potential. Supplementary Information The online version of this article (10.1007/s40037-021-00661-0) contains supplementary material, which is available to authorized users.

Implicit biases describe mental associations that affect our actions in an unconscious manner. We can hold certain implicit biases regarding members of certain social groups. Such biases can perpetuate health disparities by widening inequity and decreasing trust in both healthcare and medical education. Despite the widespread discourse about bias in medical education, teaching and learning about the topic should be informed by empirical research and best practice. In this paper, the authors provide a series of twelve tips for teaching implicit bias recognition and management in medical education. Each tip provides a specific and practical strategy that is theoretically and empirically developed through research and evaluation. Ultimately, these twelve tips can assist educators to incorporate implicit bias instruction across the continuum of medical education to improve inequity and advance justice.

INTRODUCTION: The COVID-19 pandemic has taken a significant toll on the health of structurally vulnerable patient populations as well as healthcare workers. The concepts of structural stigma and moral distress are important and interrelated, yet rarely explored or researched in medical education. Structural stigma refers to how discrimination towards certain groups is enacted through policy and practice. Moral distress describes the tension and conflict that health workers experience when they are unable to fulfil their duties due to circumstances outside of their control. In this study, the authors explored how resident physicians perceive moral distress in relation to structural stigma. An improved understanding of such experiences may provide insights into how to prepare future physicians to improve health equity. METHODS: Utilizing constructivist grounded theory methodology, 22 participants from across Canada including 17 resident physicians from diverse specialties and 5 faculty members were recruited for semi-structured interviews from April-June 2020. Data were analyzed using constant comparative analysis. RESULTS: Results describe a distinctive form of moral distress called structural distress, which centers upon the experience of powerlessness leading resident physicians to go above and beyond the call of duty, potentially worsening their psychological well-being. Faculty play a buffering role in mitigating the impact of structural distress by role modeling vulnerability and involving residents in policy decisions. CONCLUSION: These findings provide unique insights into teaching and learning about the care of structurally vulnerable populations and faculty's role related to resident advocacy and decision-making. The concept of structural distress may provide the foundation for future research into the intersection between resident well-being and training related to health equity.

In this commentary, the authors draw on 2 personal accounts of mental illness published by Kirk J. Brower, MD, and Darrell G. Kirch, MD, in this issue to consider how and why mental health stigma is maintained in medical education. In particular, they explore how perfectionism, power differentials, and structural forces drive mental illness stigma in medical education. They argue that mental health stigma in medical education, while deeply embedded in the physician archetype and medical culture, is not inevitable and that dismantling it will require individual courage, interpersonal acceptance, and institutional action.

PURPOSE Although focused reviews have characterized subsets of the literature on the arts and humanities in medical education, a large-scale overview of the field is needed to inform efforts to strengthen these approaches in medicine. METHOD The authors conducted a scoping review in 2019 to identify how the arts and humanities are used to educate physicians and interprofessional learners across the continuum of medical education in Canada and the United States. A search strategy involving 7 databases identified 21,985 citations. Five reviewers independently screened the titles and abstracts. Full-text screening followed (n = 4,649). Of these, 769 records met the inclusion criteria. The authors performed descriptive and statistical analyses and conducted semi-structured interviews with 15 stakeholders. RESULTS The literature is dominated by conceptual works (n = 294) that critically engaged with arts and humanities approaches or generally called for their use in medical education, followed by program descriptions (n = 255). The literary arts (n = 197) were most common. Less than a third of records explicitly engaged theory as a strong component (n = 230). Of descriptive and empirical records (n = 424), more than half concerned undergraduate medical education (n = 245). There were gaps in the literature on interprofessional education, program evaluation, and learner assessment. Programming was most often taught by medical faculty who published their initiatives (n = 236). Absent were voices of contributing artists, docents, and other arts and humanities practitioners from outside medicine. Stakeholders confirmed these findings resonated with their experiences. CONCLUSIONS This literature is characterized by brief, episodic installments, privileging a biomedical orientation, and largely lacking a theoretical frame to weave the installments into a larger story that accumulates over time and across subfields. These findings should inform efforts to promote, integrate, and study uses of the arts and humanities in medical education.

Implicit bias recognition and management curricula are offered as an increasingly popular solution to address health disparities and advance equity. Despite growth in the field, approaches to implicit bias instruction are varied and have mixed results. The concept of implicit bias recognition and management is relatively nascent, and discussions related to implicit bias have also evoked critique and controversy. In addition, challenges related to assessment, faculty development, and resistant learners are emerging in the literature. In this context, the authors have reframed implicit bias recognition and management curricula as unique forms of transformative learning that raise critical consciousness in both individuals and clinical learning environments. The authors have proposed transformative learning theory (TLT) as a guide for implementing educational strategies related to implicit bias in health professions. When viewed through the lens of TLT, curricula to recognize and manage implicit biases are positioned as a tool to advance social justice.

The growing numbers of refugees and immigrants from conflict-prone areas settling throughout the world bring several challenges for those working in the mental health care system. Immigrants and refugees of all ages arrive with complex and nuanced mental health histories of war, torture, and strenuous migration journeys. Many of the challenges of addressing the health care needs for this growing population of immigrants and refugees are often unfamiliar, and thus practices to address these challenges are not yet routine for care providers and health care organizations. In particular, complex trauma can make mental health assessments difficult for health care organizations or care providers with limited experience and training in transcultural or trauma-informed care. Using a transcultural approach can improve assessment and screening processes, leading to more effective and high-quality care for immigrant and refugee families experiencing mental health disorders. This paper presents findings from an assessment of current mental health services focusing on current practices and experiences with immigrant and refugee patients and families. The difficulties in developing shared understandings about mental health can hinder the therapeutic process; therefore, it is imperative to ensure an effective assessment right from the beginning, yet there is limited use of existing cultural formulation tools from the DSM-IV or DSM-5. The paper outlines current practices, approaches, challenges, and recommendations shared by mental health care providers and program leaders in addressing the mental health care needs of immigrants and refugees. The results from this study demonstrate that there are many challenges and inconsistencies in providing transcultural, trauma-informed care. Respondents emphasized the need for a thorough yet flexible and adaptive approach that allows for an exploration of differences in cultural interpretations of mental health. Our study concluded that ensuring a mindful, reflexive, transcultural, and trauma-informed health care workforce, and a learning environment to support staff with education, resources, and tools will improve the health care experiences of immigrants and refugees in the mental health care system.

The purpose of this study was to obtain perspectives from caregivers of emerging adults (ages 16–25) who were accessing mental health care services. Using constructivist grounded theory, nine caregivers participated in focus groups or individual interviews. Results suggest that caregivers' experiences centered on three areas: the emotions that they experienced (having frustration, feeling burdened, not being helped, and perceiving a lack of options), the actions that they took in their caregiver role (care facilitation and advocacy), and the external forces that perpetuated negative emotions and adversely impacted caregiver ability to facilitate and advocate (crisis-driven system, wait times, and substance misuse). Findings illustrate the impact of external forces on caregiver feelings and actions, reflecting a system that perpetuates the cycle of wait times and helplessness.

Research indicates a decline in mental health service utilization between the ages of 16 to 25, leaving emerging adults with mental illness at risk for worsening outcomes. The authors utilized a community-based participatory research (CBPR) approach to explore the mental health landscape for youth aged 16–25 in London, Canada. Interviews and focus groups (n = 30) with community and hospital system leaders, youth and caregivers were transcribed and coded using an approach informed by constructivist grounded theory. There was consensus regarding difficulties in the current system including wait times and crisis-driven services leading to powerlessness among youth and caregivers. Solutions include delivery of services through a flexible, real-time system that emphasizes patient and caregiver engagement, youth centric services and recovery-oriented care across the hospital/community continuum. The results highlight that disparate stakeholders agree regarding the need for transformational change shifting away ...

KEY POINTS For more than a decade, women have predominated among Canadian medical school graduates, according to data from the Canadian Post-M.D. Education Registry (CAPER). Although, as a profession, medicine still sees pervasive discrimination that disadvantages certain groups over others, one

Introduction Implicit bias is a growing area of interest among educators. Educational strategies used to elicit awareness of implicit biases commonly include the Implicit Association Test (IAT). Although the topic of implicit bias is gaining increased attention, emerging critique of the IAT suggests the need to subject its use to greater theoretical and empirical scrutiny. Methods The authors employed a meta-narrative synthesis to review existing research on the use of the IAT in health professions education. Four databases were searched using key terms yielding 1151 titles. After title, abstract and full-text screening, 38 articles were chosen for inclusion. Coding and analysis of articles sought a meaningful synthesis of educational approaches relating to the IAT, and the assumptions and theoretical positions that informed these approaches. Results Distinct, yet complementary, meta-narratives were found in the literature. The dominant perspective utilizes the IAT as a metric of implicit bias to evaluate the success of an educational activity. A contrasting narrative describes the IAT as a tool to promote awareness while triggering discussion and reflection. Discussion Whether used as a tool to measure bias, raise awareness or trigger reflection, the use of the IAT provokes tension between distinct meta-narratives, posing a challenge to educators. Curriculum designers should consider the premise behind the IAT before using it, and be prepared to address potential reactions from learners such as defensiveness or criticism. Overall, findings suggest that educational approaches regarding implicit bias require critical reflexivity regarding assumptions, values and theoretical positioning related to the IAT.

Purpose Learners and practicing health professionals may dismiss emotionally charged feedback related to self, yet little research has examined how to address feedback that threatens an individual's identity. The implicit association test (IAT) provides feedback to individuals regarding their implicit biases. Anticipating feedback about implicit bias might be emotionally charged for mental health professionals, this study explored their experience of taking the IAT and receiving their results, to better understand the challenges of identity-threatening feedback. Method The researchers sampled 32 psychiatry nurses, psychiatrists, and psychiatric residents at Western University in Ontario, Canada, after they completed the mental illness IAT and received their results. Using constructivist grounded theory, semistructured interviews were conducted from April to October 2017 regarding participants' experience of taking the IAT. Using constant comparative analysis, transcripts were iteratively coded and analyzed for results. Results While most participants critiqued the IAT and questioned its credibility, many also described the experience of receiving feedback about their implicit biases as positive or neutral. Most justified their implicit biases while acknowledging the need to better manage them. Conclusions These findings highlight a feedback paradox, calling into question assumptions regarding self-related feedback. Participants' reactions to the IAT suggest that potentially threatening self-related feedback may still be useful to participants who question its credibility. Further exploration of how the feedback conversation influences engagement with self-related feedback is needed.

PURPOSE: Implicit biases worsen outcomes for underserved and marginalized populations. Once health professionals are made aware of their implicit biases, a process ensues where they must reconcile this information with their personal and professional identities. The authors sought to explore how identity influences the process of implicit bias recognition and management.METHOD: Using constructivist grounded theory, the authors recruited 11 faculty and 10 resident participants working at an academic health science center in Canada. Interviews took place from June to October 2017. Participants took an online version of the mental illness implicit association test (IAT) which provides users with their degree of implicit dangerousness bias toward individuals with either physical or mental illness. Once they completed the IAT, participants were invited to draw a rich picture and interviewed about their picture and experience of taking their IAT. Data were analyzed using constant comparative procedures to develop focused codes and work toward the development of a deeper understanding of relationships among themes.RESULTS: Once implicit biases were brought into conscious awareness, participants acknowledged vulnerabilities which provoked tension between their personal and professional identities. Participants suggested that they reconcile these tensions through a process described as striving for the ideal while accepting the actual. Relationships were central to the process; however, residents and faculty viewed the role of relationships differently.CONCLUSIONS: Striving for self-improvement while accepting individual shortcomings may provide a model for addressing implicit bias among health professionals, and relational dynamics appear to influence the process of recognizing and managing biases.

Purpose Implicit bias can adversely affect health disparities. The implicit association test (IAT) is a prompt to stimulate reflection; however, feedback about bias may trigger emotions that reduce the effectiveness of feedback interventions. Exploring how individuals process feedback about implicit bias may inform bias recognition and management curricula. The authors sought to explore how health professionals perceive the influence of the experience of taking the IAT and receiving their results. Method Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 21 pediatric physicians and nurses at the Schulich School of Medicine and Dentistry, Western University, Ontario, Canada, from September 2015 to November 2016 after they completed the mental illness IAT and received their result. Data were analyzed using constant comparative procedures to work toward axial coding and development of an explanatory theory. Results When provided feedback about their implicit attitudes, participants described tensions between acceptance and justification, and between how IAT results relate to idealized and actual personal and professional identity. Participants acknowledged desire for change while accepting that change is difficult. Most participants described the experience of taking the IAT and receiving their result as positive, neutral, or interesting. Conclusions These findings contribute to emerging understandings of the relationship between emotions and feedback and may offer potential mediators to reconcile feedback that reveals discrepancies between an individual's actual and idealized identities. These results suggest that reflection informed by tensions between actual and aspirational aspects of professional identity may hold potential for implicit bias recognition and management curricula.

Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula - such as individual and contextual variables, as well as formal and informal cultural influences - are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.

OBJECTIVES: Suicide-related emergency department (ED) visits by children are increasing in tandem with suicide-related Internet content. Following the announcement of Amanda Todd’s suicide, her YouTube video received widespread views, providing an opportunity to explore this association. METHODS: Our research question was: Among Ontario children age 11–17 years, was the release of Amanda Todd’s YouTube video following her death announcement in October 2012 associated with an increase in average monthly ED visit rates for suicide-related diagnoses? We performed an interrupted time series analysis from April 2002 to December 2013, with the primary outcome as a composite of the average monthly rate of initial ED visits for suicidal ideation, intentional self-poisoning, and intentional self-harm. Secondary outcomes were average monthly rates of intensive care unit (ICU) admission and death resulting from the index visit. RESULTS: There was a statistically significant increase in the monthly ED visit rate for the composite outcome ( p = 0.02) and death or ICU admission ( p = 0.006) from April 2002 to December 2013. There was no significant change in ED visit rate for the composite outcome before and after the announcement of Amanda Todd’s death, overall (119.8 versus 219.2 respectively, p = 0.5), among females (167.4 versus 316.8 respectively, p = 0.47) or among males (74.7 versus 116.9 respectively, p = 0.33). CONCLUSIONS: Ontario ED visits for suicide-related diagnoses in 11–17 year olds increased from 2002 to 2013. However, the increase from October 2012 to December 2013 could not be attributed to a highly publicized adolescent suicide. Our findings suggest that suicide-related Internet content is not associated with the increase in ED visits for suicidal behaviour.

Introduction: Stigmatizing attitudes and behaviours towards patients with mental illness have negative consequences on their health. Despite research regarding educational and social contact-based interventions to reduce stigma, there are limitations to the success of these interventions for individuals with deeply held stigmatizing beliefs. Our study sought to better understand the process of implicit mental illness stigma in the setting of a paediatric emergency department to inform the design of future educational interventions. Methods: We conducted a qualitative exploration of mental illness stigma with interviews including physician, nurse, service user, caregiver and administrative staff participants (n = 24). We utilized the implicit association test as a discussion prompt to explore stigma outside of conscious awareness. We conducted our study utilizing constructivist grounded theory methodology, including purposeful theoretical sampling and constant comparative analysis. Results: Our study found that the confluence of socio-cultural, cognitive and emotional forces results in labelling of patients with mental illness as time-consuming, unpredictable and/or unfixable. These labels lead to unintentional avoidance behaviours from staff which are perceived as prejudicial and discriminatory by patients and caregivers. Participants emphasized education as the most useful intervention to reduce stigma, suggesting that educational interventions should focus on patient-provider relationships to foster humanizing labels for individuals with mental illness and by promoting provider empathy and engagement. Discussion: Our results suggest that educational interventions that target negative attributions, consider socio-cultural contexts and facilitate positive emotions in healthcare providers may be useful. Our findings may inform further research and interventions to reduce stereotypes towards marginalized groups in healthcare settings.

This article was migrated. The article was not marked as recommended. Mental illness stigma can have disastrous consequences for patients, families and healthcare organizations. Unconscious bias informed education seeks a systematic approach to addressing implicit biases in healthcare providers by promoting awareness and understanding in order to promote compassion and empathy. After a 1 hour intervention, third year medical students who were enrolled in the third year psychiatry clerkship rotation completed a demographic form, (pre/post) a shortened mental illness implicit association test (IAT) and the Brief Mental Illness Attitudes Scale (BMIAS). For the IAT, the majority (51.4%) of participants demonstrated a bias that mental illness was associated with dangerousness. A paired samples t test of BMIAS scores found no significant change in pre and post scores on Responsibility subscale. There was a statistically significant improvement in the in the Traits subscale from pre (n=87, m=5.15, sd=0.87) and post (n=87, m=5.62, sd=0.71), t(86)=5.16 p