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While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies.In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective.The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences.The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

Discomfort is a constant presence in the practice of medicine and an oft-ignored feature of medical education. Nonetheless, if approached with thoughtfulness, patience, and understanding, discomfort may play a critical role in the education of physicians who practice with excellence, compassion, and justice. Taking Plato's notion of aporia-a moment of discomfort, perplexity, or impasse-as a starting point, the author follows the meandering path of aporia through Western philosophy and educational theory to argue for the importance of discomfort in opening up and orienting perspectives toward just and humanistic practice. Practical applications of this approach include problem-posing questions (from the work of Brazilian education theorist Paulo Freire), exercises to "make strange" beliefs and assumptions that are taken for granted, and the use of stories-especially stories without endings-all of which may prompt reflection and dialogical exchange. Framing this type of teaching and learning in Russian psychologist L.S. Vygotsky's theories of development, the author proposes that mentorship and dialogical interactions may help learners to navigate through moments of discomfort and uncertainty and extend the edge of learning. This approach may give birth to a zone of proximal development that is enriched with explorations of self, others, and the world.

In this article the authors review the current-day definition of professionalism through the lens of the two ongoing pandemics: COVID-19 and racism. The pandemics have led to contemporary practice-related questions, such as: does professionalism entail that health care providers (HCP) be compelled to treat patients without PPE or if patients refuse to wear masks? And what role do HCP play in society when confronted with glaring health disparities and police brutality? The authors propose using care ethics as a theory to view professionalism, as it takes into account broadly encompassing relationships between HCP and society, history and context. Professionalism viewed through a care ethics lens would require professionalism definitions to be expanded to allow for interventions, i.e., not just refrain from doing harm but actively interfere or take action if wrong is being witnessed. Principles related to the primacy of patient welfare need to be re-addressed to prevent systematic self-sacrifice which results in harm to HCP and burnout. Mature care should be a characteristic of professionalism ensuring that HCP care for the sick but be practically wise, highlighting the importance of balancing too little and too much care for self and others. Professionalism needs to be viewed as a bi-directional relational exchange, with society demonstrating solidarity with those providing care. Additionally, given the scale of health disparities, simply stating that HCP need to work towards social justice oversimplifies the problem. Professionalism needs to encompass incorporating critical action and critical pedagogy into health care training and the health care profession to demonstrate solidarity with those impacted by racism.

In these days of overwhelming clinical work, decreased resources, and increased educational demands, time has become a priceless commodity. Competency-based medical education attempts to address this challenge by increasing educational efficiency and decreasing the "steeping" of learners in clinical activities for set durations of time. However, in this environment, how does one teach for compassionate, humanistic practice? The answer arguably lies in clinician-teachers' recognition and engagement in a different type of time, that of kairos. Ancient Greek thought held that there were 2 interrelated types of time: chronological, linear, quantitative time-chronos-and qualitative, opportune time-kairos. Unlike chronos, kairos involves a sense of the "right time," the "critical moment," the proportionate amount. Developing a sense of kairos involves learning to apply general principles to unique situations lacking certainty and acting proportionally to need and context. Educationally, it implies intervening at the critical moment-the moment in which a thoughtful question, comment, or personal expression of perplexity, awe, or wonder can trigger reflection, dialogue, and an opening up of perspectives on the human dimensions of illness and medical care. A sensibility to kairos involves an awareness of what makes a moment "teachable," an understanding of chance, opportunity, and potential for transformation. Above all, inviting kairos means grasping an opportunity to immerse oneself and one's learners-even momentarily-into an exploration of patients and their stories, perspectives, challenges, and lives.

Background Training future physicians to provide compassionate, equitable, person-centered care remains a challenge for medical educators. Dialogues offer an opportunity to extend person-centered education into clinical care. In contrast to discussions, dialogues encourage the sharing of authority, expertise, and perspectives to promote new ways of understanding oneself and the world. The best methods for implementing dialogic teaching in graduate medical education have not been identified. Objective We developed and implemented a co-constructed faculty development program to promote dialogic teaching and learning in graduate medical education. Methods Beginning in April 2017, we co-constructed, with a pilot working group (PWG) of physician teachers, ways to prepare for and implement dialogic teaching in clinical settings. We kept detailed implementation notes and interviewed PWG members. Data were iteratively co-analyzed using a qualitative description approach within a constructivist paradigm. Ongoing analysis informed iterative changes to the faculty development program and dialogic education model. Patient and learner advisers provided practical guidance. Results The concepts and practice of dialogic teaching resonated with PWG members. However, they indicated that dialogic teaching was easier to learn about than to implement, citing insufficient time, lack of space, and other structural issues as barriers. Patient and learner advisers provided insights that deepened design, implementation, and eventual evaluation of the education model by sharing experiences related to person-centered care. Conclusions While PWG members found that the faculty development program supported the implementation of dialogic teaching, successfully enabling this approach requires expertise, willingness, and support to teach knowledge and skills not traditionally included in medical curricula.

The time of COVID-19 is the time of storytelling-stories of chaos, loss, and despair, but also of victories large and small, acts of kindness, and deep connections. Stories are a way to pass on meaning from one person to another, among communities, and across generations. COVID-19 stories are being used in the education of physicians, but for whose benefit and to what end? What if the "heroic" frontline worker is experiencing burnout or working out of necessity rather than by choice? What if the battle against an invisible enemy does not end triumphantly but becomes an interminable war of attrition? It is important not only to propose new questions but also to create spaces for stories that do not fit conveniently into standard narratives. Stories help foster the energy and drive to write about what is next and to act as physicians in the service of human beings and their lives.

Summary Surgeons are frequently perceived by medical students to be uncompassionate, resolute and individualistic. Surgical education often prioritizes teaching and learning approaches that perpetuate these perceptions. In other specialties, engaging patients in education has shown promise in refocusing attention from the technical and procedural aspects of care toward the humanistic and social aspects. Despite proven favourable outcomes for both patients and students in many clinical areas, a "patient as teacher" approach to surgical education has yet to be adopted widely in Canada. A patient as teacher program was developed for surgical clerks at the University of Toronto with the goal of emphasizing the humanity of the patient, the psychosocial impact of a surgical diagnosis of breast cancer on patients and their families, and the social and humanistic roles for surgeons in providing patient-centred care. We report on the program's development process and pilot session.

Medical schools are increasingly called to include social responsibility in their mandates. As such, they are focusing their attention on the social determinants of health (SDOH) as key drivers in the health of the patients and communities they serve. However, underlying this emphasis on the SDOH is the assumption that teaching medical students about the SDOH will lead future physicians to take action to help achieve health equity. There is little evidence to support this belief. In many ways, the current approach to the SDOH within medical education positions them as "facts to be known" rather than as "conditions to be challenged and changed." Educators talk about poverty but not oppression, race but not racism, sex but not sexism, and homosexuality but not homophobia. The current approach to the SDOH may constrain or even incapacitate the ability of medical education to achieve the very goals it lauds, and in fact perpetuate inequity. In this article, the authors explore how "critical consciousness" and a recentering of the SDOH around justice and inequity can be used to deepen collective understanding of power, privilege, and the inequities embedded in social relationships in order to foster an active commitment to social justice among medical trainees. Rather than calling for minor curricular modifications, the authors argue that major structural and cultural transformations within medical education need to occur to make educational institutions truly socially responsible.

Recent attention to racial disparities in law enforcement, highlighted by the death of Freddie Gray, raises questions about whether medical education adequately prepares physicians to care for persons particularly affected by societal inequities and injustice who present to clinics, hospitals, and emergency rooms. In this Perspective, the authors propose that medical school curricula should address such concerns through an explicit pedagogical orientation. The authors detail two specific approaches-antiracist pedagogy and the concept of structural competency-to construct a curriculum oriented toward appropriate care for patients who are victimized by extremely challenging social and economic disadvantages and who present with health concerns that arise from these disadvantages. In memory of Freddie Gray, the authors describe a curriculum, outlining specific strategies for engaging learners and naming specific resources that can be brought to bear on these strategies. The fundamental aim of such a curriculum is to help trainees and faculty understand how equitable access to skilled and respectful health care is often denied; how we and the institutions where we learn, teach, and work can be complicit in this reality; and how we can work toward eliminating the societal injustices that interfere with the delivery of appropriate health care.

Learning the societal roles and responsibilities of the physician may involve difficult, contentious conversations about topics such as race, gender, sexual orientation, and class, as well as violence, inequities, sexual assault, and child abuse. If not done well, these discussions may be deeply traumatizing to learners for whom these subjects "cut close to the bone." Equally traumatizing is exposure to injustice and mistreatment, as well as to the sights, sounds, and smells of suffering and pain in the clinical years. This potential for iatrogenic educational trauma remains unaddressed, and medical educators must take responsibility for attending to it. Possible solutions include trigger warnings or statements given to students before an educational activity that may cause personal discomfort. The authors of this Perspective assert, however, both that this concept does not distinguish between psychological trauma and discomfort and that well-intentioned trigger warnings target the wrong goal-the avoidance of distress. Exposure to discomfort not only is unavoidable in the practice of medicine but may be crucial to personal and professional moral development. The authors argue that a more appropriate solution is to create safe spaces for dialogues about difficult topics and jarring experiences. This approach places even the notion of free speech under a critical lens-it is not an end in itself but a means to create a professional ethic dedicated to treating all individuals with excellence and justice. Ultimately, this approach aspires to create an inclusive curriculum sensitive to the realities of teaching and learning in increasingly diverse societies.

Trust is a fundamental tenet of the patient-physician relationship and is central to providing person-centered care. Because trust is profoundly relational and social, building trust requires navigation around issues of power, perceptions of competence, and the pervasive influence of unconscious bias-processes that are inherently complex and challenging for learners, even under the best of circumstances. The authors examine several of these challenges related to building trust in the patient-physician relationship. They also explore trust in the student-teacher relationship. In an era of competency-based medical education, a learner has the additional duty to be perceived as "entrustable" to 2 parties: the patient and the preceptor. Dialogue, a relational form of communication, can provide a framework for the development of trust. By engaging people as individuals in understanding each other's perspectives, values, and goals, dialogue ultimately strengthens the patient-physician relationship. In promoting a sense of agency in the learner, dialogue also strengthens the student-teacher relationship by fostering trust in oneself through development of a voice of one's own.

The introduction of the humanities—literature, history, the fine arts, and philosophy—is becoming increasingly popular in medical education. However, the overall role and educational purpose of the humanities in medical education are not clear. The oft-expressed assumption that “exposure to humanities makes one more humanistic,” is a truism that has been justifiably challenged. In fact, introducing the humanities into a context in which their importance and “efficacy” in creating humanistic doctors is assessed by the same means as that assessing biomedical or clinical knowledge and skills (e.g., standardization, observable outcomes, fulfillment of competencies, simulations) arguably risks compromising the very value that the humanities bring to explorations of the human dimensions of illness and care. This chapter is devoted to an exploration of the aims of engaging the humanities in medical education and a discussion of specific pedagogical approaches in educating physicians for humanistic practice. In particular, the role of stories, dialogues, and reflection on the moral, existential, and interpersonal dimensions of medicine will be considered; and examples of specific educational practices from the authors’ own experiences will be used to illustrate how educational and social theory may be used to design learning activities that foster an orientation toward a practice of medicine that embodies excellence, compassion, and justice.

Objectives Although many medical schools include arts-based activities in their curricula, empirical evidence is lacking regarding how the creation of art might impact medical students and their professional development. We used a qualitative research design in order to understand this process. Methods We conducted and analysed interviews with 16 medical students who had created and presented original artwork in the context of a required narrative-based undergraduate medical education programme. Teams of students collaborated to create interpretive projects based on common themes arising from conversations with individuals with chronic illness and their families. Open-ended questions were utilised to explore the conceptualisation and presentation of the projects, the dynamics of teamwork and the meaning(s) they might have for the students' professional development. We identified themes using repeated contextual reading of the transcripts, which also enhanced accuracy of the interpretations and ensured saturation of themes. Results Several major themes and sub-themes were identified. The creation of art led to a sense of personal growth and development, including reflection on past life experiences, self-discovery and an awareness of art as a creative outlet. Students also reported an enhanced sense of community and the development of skills in collaboration. Lastly, students reflected on the human dimensions of illness and medical care and identified an enhanced awareness of the experience of those with illness. Conclusions A programme involving the creation of art based on stories of illness encouraged students’ explorations of conceptions of the self, family and society, as well as illness and medical care, while enhancing the development of a collaborative and patient-centred worldview. Creative art can be a novel educational tool to promote a reflective, humanistic medical practice.

The idea of exporting the concept of reflective practice for a global medical education audience is growing. However, the uncritical export and adoption of Western concepts of reflection may be inappropriate in non-Western societies. The emphasis in Western medical education on the use of reflection for a specific end--that is, the improvement of individual clinical practice--tends to ignore the range of reflective practice, concentrating on reflection alone while overlooking critical reflection and reflexivity. This Perspective places the concept of reflective practice under a critical lens to explore a broader view for its application in medical education outside the West. The authors suggest that ideas about reflection in medicine and medical education may not be as easily transferable from Western to non-Western contexts as concepts from biomedical science are. The authors pose the question, When "exporting" Western medical education strategies and principles, how often do Western-trained educators authentically open up to the possibility that there are alternative ways of seeing and knowing that may be valuable in educating Western physicians? One answer lies in the assertion that educators should aspire to turn exportation of educational theory into a truly bidirectional, collaborative exchange in which culturally conscious views of reflective practice contribute to humanistic, equitable patient care. This discussion engages in troubling the already-muddy waters of reflective practice by exploring the global applicability of reflective practice as it is currently applied in medical education. The globalization of medical education demands critical reflection on reflection itself.

More than 100 years ago, Osler inspired educators to consider health professions education (HPE) as intricately reliant on patients. Since that time, patient involvement in HPE has taken on many different meanings. The result is a disparate body of literature that is challenging to search, making it difficult to determine how to continue to build knowledge in the field. To address this problem, we conducted a review of the literature on patient involvement in HPE using a meta-narrative approach. The aim of the review was to synthesize how questions of patient involvement in HPE have been considered across various research traditions and over time. In this paper, we focus on three scholarly communities concerned with various interpretations of patient involvement in HPE—patient as teachers, real patients as standardized patients, and bedside learning. Focus on these three research communities served as a way to draw out various meta-narratives in which patients are thought of in particular ways, specific rationales for involvement are offered, and different research traditions are put to use in the field. Attending to the intersections between these meta-narratives, we focus on the potentially incommensurate ways in which “active” patient engagement is considered within the broader field and the possible implications. We end by reflecting on these tensions and what they might mean for the future of patient involvement, specifically patient involvement as part of future iterations of competency based education.

Purpose: Educational approaches involving patient stories aim at enhancing empathy and patient-centered care; however, it is not known whether the influence of such programs on physician attitudes persists beyond medical school. Materials and methods: The Family Centered Experience (FCE) paired preclinical medical students with patient families over two years and engaged students in reflective dialogs about the volunteers’ stories. This study examined possible long-term influences on attitudes toward medicine and doctoring. Interviews were conducted with former students at the end of or after post-graduate training. All had completed the FCE between 4 and 10 years before the study. Thematic analysis was informed by a constructivist Grounded Theory approach. Results: Several themes were identified. The FCE made graduates aware of the patients’ perspectives and impacted their clinical practice in specific ways, such as developing collaborative partnerships, conducting family meetings, and breaking bad news. The course had influenced career choices and interest in teaching. Finally, the FCE enhanced appreciation of the human dimensions of medicine, which graduates had drawn upon in subsequent years. Conclusions: A program based on longitudinal interactions with individuals with chronic illness can have persistent influence by stimulating reflection on the patient’s perspective and humanistic approaches to patient care.

Slow medical education borrows from other “slow” movements by offering a complementary orientation to medical education that emphasizes the value of slow and thoughtful reflection and interaction in medical education and clinical care. Such slow experiences, when systematically structured throughout

The role of the patient in bedside teaching has long been a matter of consideration in health professions education. Recent iterations of patient engagement include patients as storytellers, members of curriculum planning committees, guest lecturers, and health mentors. While these forms of patient engagement are reported to have many benefits for learners, educators, and the patients themselves, there is concern that such programs may not be representative of the diversity of patients that health care professionals will encounter throughout their careers. This problem of representation has vexed not only educators but also sociologists and political scientists studying patients' and the public's involvement in arenas such as health services research, policy, and organizational design.In this Perspective, the authors build on these sociological and political science approaches to expand our understanding of the problem of representation in patient engage-ment. In doing so, the authors' reconfiguration of the problem sheds new light on the dilemma of representation. They argue for an understanding of representation that not only is inclusive of who is being represented but that also takes seriously what is being represented, how, and why. This argument has implications for educators, learners, administrators, and patient participants.

Although educators embrace the values that are nominally included in the idea of "the art and science of medicine," the arts and humanities have remained at the edges of medical education. One reason for this exile is the overwhelming emphasis in the curriculum on biomedical science over the social sciences and humanities. Other causes are self-inflicted-a frequent lack of theoretical rigor in the design of educational offerings and, more important, no clear answer to the question of how the humanities can make better physicians. A common justification for including the arts and humanities in medical education-that spending time with literature, music, and the visual arts contributes to student and faculty reflection and well-being-is compelling; however, it risks further marginalizing the field as a soft, feel-good supplement to training.In this Invited Commentary, the author proposes several unique ways in which the arts and humanities contribute to the development of physicians who practice with excellence, compassion, and justice.These ways include disrupting taken-for-granted beliefs and assumptions; introducing a pause in perceiving, thinking, and acting; encouraging engagement with complexity and ambiguity; seeing past the surface to historical and societal influences and causes; and encouraging an awareness of the multiple, unique voices and perspectives of patients. Ultimately, the humanities prompt awareness of the space in which physicians care for human beings in their moments of greatest need and bear witness to fundamental changes in their patients and in themselves.

In lived experience we grasp the self, neither in the form of its full course nor in the depths of what it encompasses, for the scope of conscious life rises like a small island from inaccessible depths. But an expression can tap these very depths. It is creative. Thus, in understanding, life itself can become accessible through the re-creation of creation. —Wilhelm Dilthey, 19101(p241)

PurposeThe purpose of this qualitative study was to understand what meaning(s) preclinical students attributed to participation in one-week international service–learning trips (ISLTs) and what specific experiences during the trips accounted for such perspectives.MethodTwenty-four first-year student

Explanations for race-based disparities in health and health care abound, yet the mechanisms through which individuals reach determinations of discrimination remains poorly understood. This study collected and analyzed first-person narratives from 12 African American adults regarding their interactions with the health care system to elucidate possible sources of racism and discrimination while seeking medical care. Our analysis revealed that participants reached conclusions of perceived discrimination and differential treatment through their comparative observations and intuitive judgments. In such instances, they found it necessary to develop strategies to overcome the perceived lack of attention they received. Additionally, many participants expressed a considerable difference in the quality of interpersonal interactions between themselves and some of their health care providers, compared to interactions their providers had with patients from groups that are not racially underrepresented. In such instances, participants were compelled to develop strategies to overcome what they perceived to be a lack of attention.

Objective Patients with chronic conditions are encouraged to optimize their health care experience by educating themselves regarding their condition and care. This study sought to explore the ways in which adolescents and young adults with sickle cell disease (SCD) educate others about their condition and the meanings they give to their experiences with health care professionals. Methods Seventeen individuals with SCD participated in in-depth interviews regarding their experiences as an individual with SCD seeking health care. Results Our analysis revealed participants’ belief in the ignorance concerning SCD by others, including health care professionals. Additionally, the participants suggested significant consequences of such a lack of knowledge and the strategies they used to overcome this barrier—primarily the development of the identity of patient-as-teacher. Conclusion Sickle cell patients in general and adolescent sickle cell patients in particular are often underestimated and discounted as they relate the details of their pain. This study demonstrates that these participants are not only keepers of knowledge but also must work to educate authority figures and peers in their lives to ensure they are properly cared for and that those around them understand their disease.

There are emerging links between reflection and humanistic, patient‐centered practice. We created the Family Centered Experience (FCE) to help students understand the experience of illness from the patient’s perspective. The FCE centers on students’ reflections of their conversations with their volunteer patients and families – these conversations and reflections are at the core of small group activities. The FCE Interpretive Project provides students with a chance to reflect on their volunteer’s illness experience. Students reflect on how the volunteer’s experience has influenced the way they understand the unique experience of illness and its impact on individuals, families and friends. Projects have included poems, songs, collages, paintings, quilts, sculptures, books, slide presentations, and games. By carrying forward into clerkships what they have learned from their patients and in their discussions, students are better equipped to handle the challenges of the hidden curriculum and to preserve the v...

In response to the Liaison Committee on Medical Education mandate that medical education must address both the needs of an increasingly diverse society and disparities in health care, medical schools have implemented a wide variety of programs in cultural competency. The authors critically analyze the concept of cultural competency and propose that multicultural education must go beyond the traditional notions of "competency" (i.e., knowledge, skills, and attitudes). It must involve the fostering of a critical awareness--a critical consciousness--of the self, others, and the world and a commitment to addressing issues of societal relevance in health care. They describe critical consciousness and posit that it is different from, albeit complementary to, critical thinking, and suggest that both are essential in the training of physicians. The authors also propose that the object of knowledge involved in critical consciousness and in learning about areas of medicine with social relevance--multicultural education, professionalism, medical ethics, etc.--is fundamentally different from that acquired in the biomedical sciences. They discuss how aspects of multicultural education are addressed at the University of Michigan Medical School. Central to the fostering of critical consciousness are engaging dialogue in a safe environment, a change in the traditional relationship between teachers and students, faculty development, and critical assessment of individual development and programmatic goals. Such an orientation will lead to the training of physicians equally skilled in the biomedical aspects of medicine and in the role medicine plays in ensuring social justice and meeting human needs.

To use qualitative analysis of interview transcripts with clinician-educators who facilitate small-group discussions on psychosocial themes--including doctoring--to answer the question, "What impact does facilitating small-group discussions of the patient's experience with chronic illness, the doctor-patient relationship, and doctoring have on faculty instructors' attitudes regarding their roles as clinicians and teachers?"In 2006, in-depth, face-to-face interviews using an open-ended question format were conducted with individual faculty small-group instructors teaching in the Family Centered Experience and Longitudinal Case Studies courses at the University of Michigan Medical School. Interview transcripts were analyzed using grounded theory methodology to identify emerging themes. Accuracy of interpretations and saturation of themes was confirmed by repeated contextual reading of the transcripts.Several major thematic codes emerged from the data. Facilitation of small-group discussions of psychosocial topics and doctoring fostered reflective approaches to patient care and teaching; enhanced interpersonal relationships between facilitators and their students, colleagues, and patients; and acted as a source of fulfillment and renewal among faculty facilitators.Small-group teaching of the art of doctoring may stimulate personal and professional growth among faculty facilitators and renewed interest in teaching and patient care.

The use of narratives, including physicians' and patients' stories, literature, and film, is increasingly popular in medical education. There is, however, a need for an overarching conceptual framework to guide these efforts, which are often dismissed as "soft" and placed at the margins of medical school curricula. The purpose of this article is to describe the conceptual basis for an approach to patient-centered medical education and narrative medicine initiated at the University of Michigan Medical School in the fall of 2003. This approach, the Family Centered Experience, involves home visits and conversations between beginning medical students and patient volunteers and their families and is aimed at fostering humanism in medicine. The program incorporates developmental and learning theory, longitudinal interactions with individuals with chronic illness, reflective learning, and small-group discussions to explore the experience of illness and its care. The author describes a grounding of this approach in theories of empathy and moral development and clarifies the educational value that narratives bring to medical education. Specific pedagogical considerations, including use of activities to create "cognitive disequilibrium" and the concept of transformative learning, are also discussed and may be applied to narrative medicine, professionalism, multicultural education, medical ethics, and other subject areas in medical education that address individuals and their health care needs in society.

The development of critical consciousness, anchored in principles of social justice, is an essential component of medical education.In order to assist faculty instructors in facilitating small-group discussions on potentially contentious issues involving race, gender, sexual orientation, and socioeconomic class, a faculty development workshop was created.The workshop used 'Forum Theater' techniques in which the audience was directly involved in determining the course of a simulated classroom discussion and conflict. We assessed the workshop's impact on the instructors' attitudes regarding facilitation of small-group discussions through two surveys: one to gauge immediate impressions, and another, 9-15 months later, to assess impact over time.Immediately after the workshop, participants reported that the topics covered in the sketch and in the discussion were highly relevant. In the follow-up survey, the instructors agreed that the workshop had raised their awareness of the classroom experiences of minorities and women and had offered strategies for addressing destructive classroom dynamics. 72% reported that the workshop led to changes in their behavior as facilitators. Differences in responses according to gender were observed.A workshop using interactive theater was effective in training faculty to facilitate small-group discussions about multicultural issues. This approach emphasizes and models the need to foster critical consciousness in medical education.

All physicians will care for individuals with disabilities; however, education about disabilities is lacking at most medical schools. Most of the schools that do include such education exclusively teach the medical model, in which disability is viewed as an impairment to be overcome. Disability advocates contest this approach because it overlooks the social and societal contexts of disability. A collaboration between individuals with disabilities, educators, and physicians to design a medical school curriculum on disabilities could overcome these differences.A curriculum on disabilities for first- and second-year medical students was developed during the 2013-2014 academic year and involved a major collaboration between a medical student, medical educators, disability advocates, and academic disability specialists. The guiding principle of the project was the Disability Rights Movement motto, "Nothing about us without us." Two small-group sessions were created, one for each medical school class. They included discussions about different models of disability, video and in-person narratives of individuals with disabilities, and explorations of concepts central to social perceptions of disability, such as power relationships, naming and stigmatization, and disability as identity.According to evaluations conducted after each session, students reported positive feedback about both sessions.Through this curriculum, first- and second-year medical students learned about the obstacles faced by individuals with disabilities and became better equipped to understand and address the concerns, hopes, and societal challenges of their future patients. This inclusive approach may be used to design additional curricula about disabilities for the clinical and postgraduate years.

Objective— We hypothesized that GLUT4 is a predominant facilitative glucose transporter in vascular smooth muscle cells (VSMCs), and GLUT4 is necessary for agonist-induced VSMC contraction. Methods and Results— Glucose deprivation and indinavir, a GLUT4 antagonist, were used to assess the role of GLUT4 and non-GLUT4 transporters in vascular reactivity. In isolated endothelium-denuded mouse aorta, ≈50% of basal glucose uptake was GLUT4-dependent. Norepinephrine-mediated contractions were dependent on both GLUT4 and non-GLUT4 transporters, serotonin (5-HT)-mediated contractions were mainly GLUT4-dependent, and prostaglandin (PG) F 2α -mediated contractions were dependent on non-GLUT4 transporters, whereas indinavir had no effect in GLUT4 knockout vessels. We also observed a 46% decrease in GLUT4 expression in aortas from angiotensin II hypertensive mice. Indinavir caused a less profound attenuation of maximal 5-HT–mediated contraction in these vessels, corresponding to the lower GLUT4 levels in the hypertensive aortas. Finally, and somewhat surprisingly, chronic GLUT4 knockout was associated with increased vascular reactivity compared with that in wild-type animals, suggesting that chronic absence or reduction of GLUT4 expression in VSMCs leads to opposite effects observed with acute inhibition of GLUT4. Conclusions— Thus, we conclude that GLUT4 is constitutively expressed in large arteries and likely participates in basal glucose uptake. In addition, GLUT4, as well as other non-GLUT4 facilitative glucose transporters, are necessary for agonist-induced contraction, but each transporter participates in VSMC contraction selectively, depending on the agonist, and changes in GLUT4 expression may account for some of the functional changes associated with vascular diseases like hypertension.

In order to maintain normal metabolism, the neuroretina is completely dependent on the constant delivery of glucose across the retinal microvascular endothelial cells comprising the inner blood–retinal barrier. Glucose uptake into these cells is influenced by various stimuli, including hypoxia and growth factors. Recently, insulin-like growth factor-1 (IGF-1) was shown to enhance retinal endothelial glucose transport in a process that is dependent on protein kinase C (PKC) and phosphatidylinositol-3 kinase (PI3 kinase). In the current study, the role of mitogen-activated protein kinase (MAP kinase) in regulating IGF-1 effects on retinal endothelial cell glucose transport was investigated in a bovine retinal endothelial cell (BREC) culture model. IGF-1 (25 ng/mL) caused a rapid increase in MAP-kinase activity and ERK phosphorylation. Inhibition of MAP kinase with PD98059 (100 lM) blocked IGF-1 enhancement of 2-deoxyglucose uptake. In order to clarify the relationship between PKC, PI3 kinase and MAP kinase in IGF-1 signaling in retinal endothelial cells, the effects of selective inhibitors of MAP kinase (PD98059), PKC (GF109203X), and PI3 kinase (wortmannin, LY294002) on signal transduction by IGF-1 were studied. Inhibition of MAP kinase abolished IGF-1 stimulation of PKC but had no effect on PI3 kinase activity, whereas inhibition of either PKC and PI3 kinase had no effect on MAP kinase phosphorylation or activity in IGF-1-treated cells. Taken together, these data demonstrate that IGF-1 stimulation of BREC glucose transport requires activation of MAP kinase and that MAP kinase is upstream from PKC but is independent of PI3 kinase in mediating the actions of IGF-1 on retinal endothelial cells.

To educate physicians who are capable of delivering ethical, socially responsible, patient-centered care, there have been calls for identifying curricular space for reflection on the human and societal dimensions of medicine. These appeals, however, beg the question: What does it mean to devote space in an otherwise busy curriculum for these types of reflection? This Perspective is an attempt to understand the nature of this educational space in terms of its purpose, uses, dynamics, and limitations, and the underlying components that allow reflection and transformation to occur. Reflections on psychosocial themes often take the form of dialogues, which differ from the discussions commonly encountered in clinical settings because they require the engagement of the participants' whole selves--life experiences, backgrounds, personal values, beliefs, and perspectives--in the exchanges. Dialogues allow for the inclusion of affective and experiential dimensions in addition to intellectual/cognitive domains in learning, and for an emphasis on discovering new perspectives, insights, and questions instead of limiting participants solely to an instrumental search for solutions. Although these reflections may vary greatly in their form and settings, the reflective space requires three qualities: safety and confidentiality, an intentional designation of a time apart from the distractions of daily life for reflection and dialogue, and an awareness of the transitional nature--the liminality--of a critically important period of professional identity development. In this open space of reflection and dialogue, one's identity as a humanistic physician takes form.

Dialogue-based learning can help medical students recognize, acknowledge, and overcome their biases.

Stories, film, drama, and art have been used in medical education to enhance empathy, perspective-taking, and openness to "otherness," and to stimulate reflection on self, others, and the world. Yet another, equally important function of the humanities and arts in the education of physicians is that of "making strange"-that is, portraying daily events, habits, practices, and people through literature and the arts in a way that disturbs and disrupts one's assumptions, perspectives, and ways of acting so that one sees the self, others, and the world anew. Tracing the development of this concept from Viktor Shklovsky's "enstrangement" (ostranenie) through Bertolt Brecht's "alienation effect," this essay describes the use of this technique to disrupt the "automaticity of thinking" in order to discover new ways of perceiving and being in the world.Enstrangement may be used in medical education in order to stimulate critical reflection and dialogue on assumptions, biases, and taken-for-granted societal conditions that may hinder the realization of a truly humanistic clinical practice. In addition to its ability to enhance one's critical understanding of medicine, the technique of "making strange" does something else: By disrupting fixed beliefs, this approach may allow a reexamination of patient-physician relationships in terms of human interactions and provide health care professionals an opportunity-an "open space"-to bear witness and engage with other individuals during challenging times.

When considering the teaching and learning of topics of social relevance in medicine, such as professionalism, medical ethics, the doctor-patient relationship, and issues of diversity and social justice, one is tempted to ask, are the ways of knowing in these fields different from that in the biomedical and clinical sciences? Furthermore, given that the competency approach is dominant in medical education, one might also ask, is the competency model truly appropriate for all of the types of knowledge necessary to become a good physician? These questions are not merely academic, for they are at the core of how these subjects are taught, learned, and assessed.The goal of this article is threefold: first, to explore the nature of knowing and the educational goals in different areas of medicine and, in particular, those areas that have social relevance; second, to critically review the concept of competencies when applied to education in these areas; and third, to explore alternative strategies for teaching, learning, and assessment. This discussion reflects a view that the goal of education in areas of social relevance in medicine should be the enhancement of an understanding of-a deep and abiding connection with-the social responsibilities of the physician. Moving beyond competencies, this approach aspires toward the development of practical wisdom (phronesis) which, when embodied in the physician, links the knowledge and skills of the biomedical and clinical sciences with a moral orientation and call to action that addresses human interests in the practice of medicine.

The ventromedial hypothalamus (VMH) has been proposed to be a glucose sensor within the brain and appears to play a critical role in initiating the counterregulatory response to hypoglycemia. Transport of glucose across the brain capillaries and into neurons in this region is mediated by different isoforms of the sodium-independent glucose transporter gene family. The objective of the present study was to identify the specific glucose transporter isoforms present, as well as their cellular localization, within the VMH. Immunohistochemistry was performed for GLUT1, GLUT2 and GLUT4 in frozen sections of hypothalami from normal rats. GLUT1 was present on the endothelial cells of the blood–brain barrier (BBB) of the VMH. GLUT2 immunoreactivity was seen in the ependymal cells of the third ventricle and in scattered cells in the arcuate and periventricular nuclei. There was no GLUT2 expression in the VMH. The insulin-sensitive GLUT4 isoform was localized to vascular structures within the VMH. Double-labeled immunohistochemistry demonstrated co-localization of GLUT4 with GLUT1 and with the tight junction protein ZO-1 in the VMH and suggested that VMH GLUT4 expression was restricted to the BBB. The role of GLUT4 in the brain and within the VMH is unknown, but given its location on the BBB, it may participate in brain sensing of blood glucose concentrations.

Vascular endothelial growth factor (VEGF), the strongest known angiogenic cytokine and also a potent enhancer of vascular permeability, is closely associated with diabetic ocular complications and other intraocular neovascular diseases. The therapeutic effect of VEGF-neutralizing antibody on oxygen-induced retinopathy in an experimental murine model of proliferative retinopathy was investigated. Intraocular and systemic injection of the antibody resulted in 46% and 18% reductions in the number of nuclei of newly formed vessels of this model, respectively. The results demonstrated that a neutralizing antibody against VEGF was highly effective in the treatment of intraocular neovascularization and suggested possible modes of therapy in human intraocular neovascular diseases, including diabetic proliferative retinopathy.

Pairing medical students with chronically ill community volunteers for 2 years helps those students gain appreciation for the experience of illness, develop self-reflection and perspective-taking, and learn to communicate with people who may be quite unlike them. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.