Keynote commentaries

Ahmed Hankir

Trigger Warning. This article does discuss suicidality.

I was reminded very recently how, that despite being a doctor and consultant psychiatrist, I am not ‘invincible’, that I am only human and that I am vulnerable to experiencing a ‘mental health wobble’ like everyone else. My parents live in the south of Lebanon. It has been over a year since I last saw them. The British government has been strongly advising British nationals to avoid travelling to Lebanon. But I could not ignore what my heart was saying to me. ‘You must see them Ahmed. They are vulnerable and they are getting older. They need you’.

The plane from London Heathrow to Beirut Airport was half empty (ordinarily it would be packed with passengers). Soon after my arrival in the capital of Lebanon, there were breaking reports that there had been an escalation in hostilities. After receiving these reports, I froze. ‘Is this it? Will there be another full-scale attack like there was back in 2006?’ I suddenly experienced a traumatic flashback of when I was a medical student in Manchester during the 2006 Lebanon War. I was a third year medical student at the time, and I had developed an episode of psychological distress that was so severe I was forced to interrupt my studies. However, debilitating though the symptoms were, the stigma was far, far worse. I will never forget that when I needed care and compassion the most, I received ridicule and rejection instead. It was the darkest period of my life and the lowest I have ever felt. If ever there was a rock bottom, this was it. In my despair and isolation, I contemplated ending that which is most precious, human life itself.

Memories of those dark days have not faded, and they continue to haunt me from time to time. The recent escalation of hostilities in the Middle East certainly triggered the resurfacing of traumatic memories. I was extremely fortunate to have recovered, but I was one of the lucky ones. Far too many persons—especially medical students and doctors—living with a mental health condition suffer in silence and tragically do not survive. My lived experiences with a mental health condition inspired me to embark on a mission to identify, challenge and reject mental health-related stigma in medical schools and in healthcare more broadly.

After working as a Foundation Doctor for 2 years and as an Academic Clinical Fellow in Old Age Psychiatry for a year, I took 3 years out of my specialist training in psychiatry to design, develop and deliver, ‘The Wounded Healer’. The Wounded Healer has been described as an innovative method of teaching that blends the power of the performing arts and storytelling with psychiatry. The Wounded Healer also traces my recovery journey from ‘impoverished, hopeless and suicidal service user with mental illness’ to ‘empowered survivor, World Health Organization Award winning doctor and consultant psychiatrist’. The main aims of The Wounded Healer are to entertain, engage and educate to debunk the many myths about persons living with a mental health condition that abound, to reject mental health-related stigma and to break down the barriers to mental health care services. I have been fortunate to deliver The Wounded Healer in person to over 150,000 people in 25 countries worldwide.

People often ask me, ‘Professor Hankir, with mental health related stigma seemingly ubiquitous, how do we combat it? Where do we even begin?’ My response is that the human heart is a good starting point. We must all engage in introspection, be brutally honest with ourselves and identify and remove any stigma that we may be harbouring. We must then amplify the voices of persons living with a mental health condition by providing them with a platform to share their experiences, stories and insights.

I was fortunate to receive an invitation to deliver a Keynote Lecture at the Association for the Study of Medical Education Annual Scholarship Meeting at Warwick University on the 12th of July 2024. In relation to pioneering initiatives that reject mental health related stigma the approach should be, ‘Nothing about us without us’, but it seems like the current approach is, ‘Everything about us, without us.’ That is why it was so progressive, inclusive, dignifying, empowering and humanising—as a person living with a mental health condition—to receive an invitation to deliver a Keynote Lecture at the ASME Annual Scholarship Meeting to share my story. To be honest, I have delivered talks at many conferences, but the 2024 ASME Annual Scholarship Meeting in Warwick University has to be one of the best events I have ever presented at. The connection with the organising committee and with the audience was profoundly authentic.

In my Keynote Lecture, I discussed how common mental health difficulties are among medical students and doctors. I explained how mental health-related stigma is rampant in medical schools and the NHS and that it is a formidable barrier to mental health care services. I was clear to the audience that there are likely persons in the auditorium who are experiencing mental health difficulties, however, due to fear of exposure to stigmatisation they are suffering in silence. I exclaimed that I have always embraced my vulnerability and been honest, open and transparent about my mental health experiences to reject the stigma. I elaborated and provided evidence that social contact and indeed virtual contact between a person living with a mental health condition and a person not living with a mental health condition is the most effective way of rejecting stigma. In other words, persons living with a mental health condition have the power to reject stigma, and we should be spearheading anti-stigma campaigns. However, just because being honest, open and transparent is the ‘right’ approach for me, it does not necessarily mean that it is the ‘right’ approach for others. It is a personal choice if we want to share our stories or not and we should never, ever be made to feel that we should. But also, we should never, ever be made to feel that we should not.

During my Keynote Lecture, I shared some of the tools that I personally utilised to recover and that I continue to utilise to remain resilient, namely, ‘Social connectivity, creativity, and physical activity.’ I am definitely not opposed to psychiatric drugs; I am a consultant psychiatrist after all. However, what I am opposed to is the prescribing of powerful psychotropic medications when it is not necessary. I do think that the threshold for prescribing psychiatric drugs is too low and that there is a lot we can do before we get our prescription pads out such as lifestyle interventions (increasing exercise and improving our diet, for example). Whenever we decide to start persons on psychotropic medications as part of a holistic approach to mental health, there must also be a de-prescribing plan in place.

I stressed that while we can increase our resilience by modifying our lifestyles, we must be careful and cautious about the message we might be getting across. It does not matter how many Zumba classes you attend, unless we address systemic issues such as workforce shortages for example, doctors and other health care professionals will continue to experience mental health difficulties.

I concluded my Keynote Lecture by saying that stigma has evolved and that our approach to combating stigma must also evolve. Stigma now seemingly thrives online, in digital spaces and across the different social media platforms. We must therefore create content (i.e. brief video interventions that can be posted on TikTok) featuring a person living with a mental health condition sharing their story as part of our arsenal.

My take-home messages were simple: that living with a mental health condition is absolutely nothing to be ashamed about, that effective treatment is available, that seeking help is a strength, not a weakness and that with the right support, recovery is a reality for the many and not for the few.

Professor Ahmed Hankir is author of the book Breakthrough, A Story of Hope, Resilience and Mental Health Recovery published by Capstone and is available to purchase in major retail stores and Amazon.

Lisa M. Meeks¹ and Rylee Betchkal²

¹University of Michigan, Ann Arbor, Michigan, USA; ²College at Columbia University, New York, New York, USA

Panel: Dr Lara Varpio, Dr Gabrielle Finn, Dr Yoon Soo Park, Dr Kevin Eva

Disability equity has gained increasing attention within health professions scholarship as part of broader efforts towards inclusivity and justice for marginalised populations. This growing focus highlights a critical need to address the systemic barriers faced by disabled individuals within academia, both as researchers and subjects of scholarship. To further this agenda, this topic was delivered in a keynote at the Association for the Study of Medical Education (ASME) conference in July, followed by a panel discussion featuring leading scholars in health professions education: Drs Lara Varpio, Gabrielle Finn, Yoon Soo Park and Kevin Eva. This commentary summarizes the key points from the panel, identifies the challenges inherent in the current scholarly landscape and proposes actionable strategies to promote disability equity in health professions scholarship.

The panel, recorded as a podcast and available online, captures the urgency and momentum of this critical conversation.

Introduction

Historically, individuals with disabilities have been underrepresented in health professions and the corresponding scholarship.¹ This has led to significant gaps in research and a pervasive lack of inclusivity in educational and professional environments. These inequities have broad implications, not only for the quality and relevance of research but also for the careers of disabled scholars. To address these disparities, a growing call for inclusive research and publication practices emphasises the need to centre the voices and experiences of disabled individuals while attending to their career progression within academia.²

The importance of inclusive research practices

Dr Lara Varpio, in her panel remarks, emphasised that assumptions often shape research participation, and these assumptions can limit whose voices are heard. She stated, ‘We assume who our participants are and that those assumptions do not always hold. So, we need to be thinking about enabling others who have different ways of communicating and engaging, providing them the opportunity to give voice and to be part of the data, to be part of the base of knowledge upon which we make decisions’.

Research is a powerful tool for shaping understanding, policy and practice within health professions education. However, traditional research methodologies often exclude the lived experiences of individuals with disabilities. This exclusion creates gaps in the literature and perpetuates biases that may lead to insufficiently addressing the needs of disabled individuals or creating barriers for disabled researchers. Dr Varpio highlighted the importance of ensuring disabled individuals' active participation throughout the research process to bridge these gaps.

One of the most effective ways to promote inclusivity in research is through participatory approaches that involve disabled individuals as co-researchers rather than passive subjects.² This methodology aligns with the principles of disability justice,³ which prioritise the leadership of those most impacted by the research. By involving disabled individuals as co-researchers, scholars can ensure that research questions, methodologies and interpretations are grounded in lived experiences, leading to more relevant and impactful findings.⁴

Dr Varpio also addressed how ableism—discrimination that favours non-disabled individuals and views disability as inherently negative—permeates academic research.⁵ Ableist assumptions often underpin research design, limiting the accessibility and inclusiveness of methodologies.⁶ She referenced her recent manuscript with Dr Neera Jain on universal design theory (UDT), which advocates for designing research methods that are accessible from the outset.⁷ UDT offers a framework for challenging ableist assumptions and creating more just research practices. Their paper calls on health professions educators and researchers to apply UDT principles to transform research practices and advance justice.⁷

Additionally, Dr Varpio stressed the need for leaders to create welcoming spaces for disabled individuals in academic environments. Mentorship, she argued, is a critical missing piece in advancing disability equity, and it is essential for disabled scholars to have mentors who understand the barriers they face.

Challenges in publication practices

Dr Kevin Eva expanded the conversation to the challenges disabled scholars face in publishing their research. He shared insights into how medical education is elevating EDI as an important element of research, stating, ‘We ask reviewers to comment specifically on to what extent have equity, diversity, and inclusion issues been reflected in a thoughtful and appropriate way given the particulars of the paper. So, I do not think that every paper needs to have an extensive focus on EDI, but we wanted to put that in as a means of making sure that people were not just unaware of the importance of it’. This includes encouraging reviewers to reflect on whether issues of EDI are addressed within the manuscript, even if not the primary focus.

However, without disabled individuals on editorial boards, there is a risk that disability-focused research may be misunderstood or undervalued. Representation matters significantly in peer review, where ableist assumptions and other bias may go unchallenged without a lived experience perspective.⁸ Journals should prioritise accessibility and inclusion in their review processes, and in order to realise the value of EDI work, we need more comprehensive guidelines. This is especially critical to evaluating how disability perspectives are incorporated into scholarly work.

Finally, all the panellists agreed that better representation on editorial boards and in peer review is needed to reduce the marginalisation of disability-focused work. The addition of thoughtful and deliberate inclusion of EDI practices in the review process reflects a promising shift, but much more needs to be done to normalise disability as a critical lens in health professions scholarship.

Creating space for disabled researchers

Dr Gabrielle Finn addressed the unique challenges disabled researchers face in academic spaces, particularly at conferences, where networking and collaboration are essential for career progression. She remarked, ‘We want to be as inclusive as possible and remove as many barriers for attendance as well’.

Conferences provide critical opportunities for networking, mentorship and career development, yet they often present significant barriers for disabled individuals. From inaccessible venues to insufficient accommodations, disabled researchers may find themselves excluded from these essential professional spaces. Dr Finn highlighted her efforts within ASME to create a more inclusive environment, ensuring that conference materials and venues are accessible to all attendees. Representation, too, is important. Including disabled voices in conference content and discussions ensures that disability is not tokenised but integrated into broader conversations about equity and inclusion.

Dr Finn's emphasis on inclusive conference practices underscores the importance of physical and communication access, but we must also attend to the mental and emotional toll of navigating environments not designed for inclusivity, which can be costly to both the individual and their careers as health professions researchers. Conferences should follow ASME's example and create spaces where disabled scholars can thrive, taking proactive steps to make these spaces welcoming and supportive.

Career progression for disabled scholars

Dr Yoon Soo Park focused on the barriers disabled scholars face in advancing their academic careers. He stated, ‘There's a lot of momentum, there's a lot of energy, but then sometimes there are barriers around resources, around infrastructure, and so forth’.

Disabled scholars encounter systemic obstacles in hiring, promotion and tenure processes. Bias and stigma during job interviews, assumptions about accommodation costs and rigid academic timelines often impede their career progression. Dr Park suggested that institutions align their missions with broader university goals to create strategic partnerships that unlock resources for disabled researchers. Expanding collaborations beyond traditional disciplinary boundaries and investing in infrastructure that supports disability equity research can create a more inclusive environment.

Moreover, Dr Park called for dedicated funding to support disability equity initiatives. Without institutional investment in the form of specialised databases, research coordinators and grant opportunities, the field will struggle to advance. By implementing these strategies, institutions can cultivate a more supportive environment for disabled scholars, ensuring their contributions to health professions scholarship are recognised and valued.

Best practices for inclusive scholarship and practice

Disability equity in health professions scholarship is a matter of justice and a means of enriching the field with diverse perspectives. Advancing disability equity in health professions scholarship requires embedding inclusive practices at all levels of research and publication (Table 1). Participatory research methods that involve disabled individuals as co-researchers, applying an intersectional lens that considers the multiple identities individuals hold and addressing structural barriers in publication, conferences and career progression are all critical components of this work. By adopting inclusive research methods, addressing barriers to publication and creating supportive environments for disabled scholars, we can build a more representative and equitable body of knowledge that better serves disabled individuals and communities. While challenges remain, the momentum for disability equity is growing, and health professions scholarship has a pivotal role in leading the way toward a more inclusive future.

For a deeper dive into this topic, check out the original discussion on Episode 98 of the Docs with Disabilities Podcast.

REFERENCES

1. Castro, F., Cerilli, C., Hu, L., Iezzoni, L. I., Varadaraj, V., & Swenor, B. K.. Experiences of researchers with disabilities at academic institutions in the United States. PLoS ONE 2024; 19(8). https://doi.org/10.1371/journal.pone.0299612

2. Kelly M, Brown MEL. Clarity without simplicity: researching lived experience in health professions education. Med Educ 2024; 58(9): 1017–1019. https://doi.org/10.1111/medu.15447

3. Sins Invalid. 10 principles of disability justice. Retrieved on August 20, 2024, from https://www.sinsinvalid.org/blog/10-principles-of-disability-justice

4. Kusumowardoyo CL, Wulansari HY, Songgoua I, Katapi E, Hadu YA. Co-researching with persons with disabilities: reflections and lessons learned. In Disrupting the academy with lived experience-led knowledge 2024 (pp. 80–100). Policy Press, https://doi.org/10.56687/9781447366362-010

5. Campbell, F.K. Contours of ableism: the production of disability and abledness. Palgrave Macmillan. 2009, https://doi.org/10.1057/9780230245181

6. Dolmage, J. Academic ableism: disability and higher education. University of Michigan Press. 2017, https://doi.org/10.3998/mpub.9708722

7. Jain, N., & Varpio, L. Designing for justice: how universal design theory could bolster health professional education research. Focus Health Prof Ed, 2023; 24(4), 136–150. https://doi.org/10.11157/fohpe.v24i4.791

8. Ajjawi R, Crampton PES, Ginsburg S, Mubuuke GA, Hauer KE, Illing J, Mattick K, Monrouxe L, Nadarajah VD, Vu NV, Wilkinson T, Wolvaardt L, Cleland J Promoting inclusivity in health professions education publishing. Med Educ 2022; 56(3): 252–256. https://doi.org/10.1111/medu.14724

Yoon Soo Park ([email protected])

Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA

The landscape of health professions education is changing, with an ever-growing flow of data sources that can be used as feedback for learning and developmental growth.^1,2 Trainees in the health professions are measured and assessed across a variety of assessment methodologies beyond traditional, single assessments.³

Assessment methodologies are shifting towards a ‘systems’ approach that incorporates signals from multiple assessments to make inferences about learner competence and entrustability.⁴ Learner competence is a multifaceted construct that requires multiple sources of information and may not be solely derived from single assessments. As such, the health professions education community has seen an increase in rigour around the validity of assessments, with an effort to link the systems of assessments to outcomes of learning.⁴

Emerging role of data science and assessment systems

Aligning assessment systems with outcomes. Linking systems of assessments with outcomes provides a bidirectional ‘feedforward’ and ‘feedback’ mechanism between assessments and outcomes (Figure 1). Predictive studies that align systems of assessments with outcomes provide opportunities to identify early signals for struggling learners or examining patterns of learning that informs success in transition between undergraduate and graduate medical education (‘feedforward’). At the same time, studies that link outcomes back to systems of assessment offers programmatic opportunities for improving assessments and curricular evaluation (‘feedback’).

There have been multiple studies that have emerged over the past few years linking training and learner performance with outcomes. Studies in this area have primarily addressed the feedforward aspect, including studies that examine the transition between medical school and residency⁵; performance during residency⁶; and also studies that examine residency performance with early outcomes of practicing physicians.⁷ Our field needs more studies that use the relationship between education and outcomes to examine and demonstrate efficacy in the ‘feedback’ mechanism to enhance our programmatic evaluation and curricular innovations.

Using assessments as developmental pathways. There has been a paradigm shift in the use of assessments to measure developmental pathways and progress towards meeting competence.¹ This is a relatively new approach to assessment—prior uses of assessments have focused on identifying learner readiness, competence or mastery, that is, whether the learner has reached a ‘threshold’ of acceptable standard. However, from a broader learning perspective, assessments should provide earlier information to intervene and to identify struggling learners. This work has shown that learning is highly non-linear and often incorporates multiple developmental pathways towards achieving competence (Figure 2).

The reconceptualisation of learning and assessment as a developmental pathway has provided opportunities to understand inflection points.⁶ Inflection points in developmental pathways show instances when learners struggle and may have a slower rate of progress or may even dip; there are also instances when learners accelerate their learning pathway. These inflection points provide useful opportunities for remediation and feedback. Studies are emerging to address these learning pathways and developmental inflection points, which will be important for our field with the continued emergence and advances in technology.

Developing infrastructure for data systems and multisite collaborations

Data infrastructure—educational ‘data hubs’. Educational data gathered at institutions are multifaceted and collected by multiple stakeholders, sometimes segmented by the phase of training. This unfortunately prompts a cumbersome activity of combining data sources across multiple entities; and institutions vary in their own unique data systems. Nationally, there are multiple regulatory and accreditation organisations that house different data sources depending on the mission of the regulatory organisation, including licensure, training performance and learner background information. The highly decentralised nature of data poses challenges for educational research that require merging and aggregating data to understand the diversity of learning experiences and backgrounds that trainees face. Institutions are recognising the need for educational data hubs and their value is emerging.

‘Micro’ (local), ‘macro’ (national) and ‘mezzo’ (multisite consortium) levels of educational studies. Traditionally, studies in education have relied on local examples, addressing challenges and issues faced at a single institution. These local studies that are at the ‘micro’ level of research have helped address cases that articulate innovations. However, local studies also face the issue of generalising their results to make inferences at other institutions. Over the past decade, we have seen an emergence of national studies that address educational paradigms or issues using data gathered at the national level. These national studies address macro-level phenomena for the field and generate a broad overview of trends and momentum for the health professions education community.⁸ Yet, they also have limitations in the specific details that get overlooked given the macroscopic lens that national studies encompass.

Consortium studies that bridge a network of selected education programmes to work together for a common research goal have offered vast enhancements that balance both the local and the national perspective of educational phenomena.^9,10 Consortium studies that build on multisite data address the ‘mezzo’ level of educational research—and they are increasing in the field. The mezzo-level studies not only provide specificity around assessment and learning practices within an institution, but also offer the diversity of programmes if the selection and sampling of the institutions are done with rationale and planning. While mezzo-level studies provide useful clarity on educational data and research, they also require a centralised data hub for programmes to share their data, prompting a need to have data stewardship and data use agreements. These infrastructure elements to consortium studies will continue to be needed as the field grows to develop guidance and best practices.

‘Osmosis’ effect of methodologies between health professions education and other disciplines

The rise of data science in health professions education has also called for new methodologies and paradigms to understand and study the complexity of educational data.² For example, technological advances in artificial intelligence have offered an abundance of data that are gathered instantaneously through wearable devices and other simulation modalities such as robotic simulation. Our existing frameworks in validity and quantitative methodologies may need to be updated to underscore the variation in data that emerge from these large data science paradigms. This is where we need to look beyond medical and health professions education to seek methodological innovations.⁵

Recent large-scale educational studies have noted important discoveries on the analytic nature of our educational data. For example, we have found significant clustering of trainee performance that is programme specific; and as such, ignoring programme-level clustering would generate inaccurate inferences of data. We have also found the importance of technical concepts such as cross classification that need to be addressed when analysing data, as learners trained in programme-specific environments graduate and practise in different hospitals and care for diverse patient populations. These methodologies have been developed in econometrics, health services research and in biostatistics. We need to make an effort to bridge these methodological advances (both quantitative and qualitative) into our work in the health professions.

We should also note that exchange of methodological innovations is not a one-directional pathway. We have also exported innovations emerging from the health professions into other disciplines, creating an ‘osmosis’ effect of methodological innovations. Researchers and scientists are referencing our work in assessments (simulations and workplace-based assessments) to enhance methodology in other disciplines and in other emerging fields.⁴

Challenges and opportunities in educational data science

Linking educational data with outcomes is a fundamental mission for our field and generates value in training and learning. As educators, we aspire to demonstrate that better training and educational practices can lead to improvements in health care and outcomes for patients. This effort builds on the model of translational science in the basic sciences for education. However, we should also recognise the importance of this weighty task and the caution that may be exercised with this activity.

Caution for predictive studies. Predictive studies should be done with caution and not necessarily used to permit exploratory correlations that may lead to unintended or unethical consequences for learning or for trainees.¹¹ Learning occurs in diverse environments, with trainees who come from many backgrounds. And as such, predictive studies should not merely be an activity to connect data points to make inferences, but also have theory-informed justification and rationale. Methodologies that can address learner backgrounds should also be considered for just and fair inferences.¹²

We are entering a new transformative phase of data science and educational research that can enrich our understanding of how learning can be optimised and to offer better training opportunities for learners. We will see new paradigms in assessments and measurements being developed, new data infrastructure and stewardship guidelines and also emergence of innovative methodologies that cut boundaries between disciplines. The emergence of new tools and data science methodologies will call for standards and frameworks that guide our scholarship and practice in health professions education.

REFERENCES

1. Holmboe ES, Yamazaki K, Hamstra H. (2020). The evolution of assessment: thinking longitudinally and developmentally. Acad Med, 95;11S:S7–S9, https://doi.org/10.1097/ACM.0000000000003649

2. Tolsgaard MG, Boscardin CK, Park YS, Cuddy MM, Sebok-Syer S. (2020). The role of data science and machine learning in health professions education: practical applications, theoretical contributions, and epistemic beliefs. Adv Health Sci Educ Theory Pract, 25;5:1057–1086, https://doi.org/10.1007/s10459-020-10009-8

3. Park YS, Zar F, Tekian A. (2020). Synthesizing and reporting milestones-based learner analytics: validity evidence from a longitudinal cohort of internal medicine residents. Acad Med, 95;4:599–608, https://doi.org/10.1097/ACM.0000000000002959

4. Yudkowsky R, Park YS, Downing S. (2019). Assessment in health professions education. 2nd Ed. New York; Routledge, https://doi.org/10.4324/9781315166902

5. Park YS, Ryan MS, Hogan SO, Berg K, Eickmeyer A, Fancher TL, Farnan J, Lawson L, Turner L, Westervelt M, Holmboe E, Santen SA. (2023) Transition to residency: national study of factors contributing to variability in learner milestones ratings in emergency medicine and family medicine. Acad Med, 98;11S:S123–S132, https://doi.org/10.1097/ACM.0000000000005366

6. Park YS, Hamstra SJ, Yamazaki K, Holmboe E. (2021). Longitudinal reliability of milestones-based learning trajectories in family medicine residents. JAMA Open, 4;12: e2137179, https://doi.org/10.1001/jamanetworkopen.2021.37179

7. Smith BK, Yamazaki K, Tekian A, Brooke BS, Mitchell EL, Park YS, Holmboe ES, Hamstra SJ. (2024). Accreditation Council for Graduate Medical Education Milestone training ratings and surgeons' early outcomes. JAMA Surg, 159;5:546–552, https://doi.org/10.1001/jamasurg.2024.0040

8. Holmboe ES, Yamazaki K, Nasca TJ, Hamstra SJ. Using longitudinal milestones data and learning analytics to facilitate professional development of residents: early lessons from three specialties. Acad Med, 95;1:97–103, https://doi.org/10.1097/ACM.0000000000002899

9. Schwartz A, King B, Mink R, Turner T, Abramson E, Blankenburg R, Degnon L. (2023). The APPD longitudinal educational assessment research network's first decade. Paediatrics, 151;5: e2022059113, https://doi.org/10.1542/peds.2022-059113

10. Schwartz A, Young R, Hicks PJ. (2016). Medical education practice-based research networks: facilitating collaborative research. Med Teach, 38;1:64–74, https://doi.org/10.3109/0142159X.2014.970991

11. Park YS, Roberts LW. (2022). Drawing a line between 2 points: challenges and opportunities in linking assessments with key educational outcomes. Acad Med, 97;10:1427–1428, https://doi.org/10.1097/ACM.0000000000004910

12. Hauer KE, Park YS, Bullock JL, Tekian A. “My assessments are biased!” Measurement and sociocultural approaches to achieve fairness in assessment in medical education. Acad Med, 98;8S:S16-S27, https://doi.org/10.1097/ACM.0000000000005245

Lara Varpio

I recently had a difficult scholarly collaboration. I had relied on someone to do a significant part of a project, but that individual just did not get it done. Apologies were offered. Mitigating circumstances were described. And, of course, I understood. I too have suffered the slings and arrows of outrageous fortune.¹ We all have. I wish I could write that, behind the closed door of my office, I faced this problem with grace and dignity. But I did not. I just cried. I felt crushed under a mountain of work that needed to be redone. I had no warning that this was about to land on my desk. This project has a hard deadline that is a mere 3.5 months away. My calendar is notoriously overloaded. And a variety of other unexpected situations had already added additional demands on my time. This was the straw that broke my proverbial back.

I was in tears, weeping with frustration and exhaustion. I was suddenly, unexpectedly buried in work, feeling overwhelmed and alone. All I could think was: ‘I'm a failure’.

Once I pulled myself together enough to have some rational, logical thoughts, I knew what to do. I reached out to a friend—who also happens to be my immediate local colleague—and asked if she could help me. I was desperately uncomfortable asking for help—not because I was ashamed that I needed her aid, but because I know she too is carrying a full workload. I know her calendar is similarly overloaded. I did not want to make my problem, her problem. I asked her in a text and offered several reasons why I thought she should decline. I implored with her to say ‘no’ if she did not have the bandwidth to step into this fray. She generously, graciously and immediately offered to help. She was rolling up her sleeves in instantaneous response to my plea.

I was in tears, again. This time, I wept tears of relief and appreciation. I was flooded with one thought: ‘Thank heavens for Dorene’.

As I regrouped myself and crafted a plan to resolve this problem, I realised that other colleagues would likely also respond with a generous, gracious and immediate offer to help. I spent the next 2 hours devising a divide-and-conquer strategy, and then I wrote to others asking help. Before the day's end, I had a plan and a team. Yes, I was going to have to work nights and weekends in the 3.5 months ahead, but the mountain of work had dissolved into manageable pieces that could be distributed among trusted colleagues.

And because it was that kind of afternoon …

I was in tears, again. I found myself crying with gratitude for my community. I had a new thought dominating my thinking: ‘I can do this because we can do this’.

Why am I writing so publicly about an afternoon of emotional meltdowns? I feel compelled to share this story because it is about the power of community. I was able to quickly turn tears of frustration into tears of gratitude thanks to my immediate and extended community. However, I fear that the strength of our health professions education (HPE) communities is at risk. When I look across the HPE landscape, I see several reasons why our communities are in jeopardy.

How our local community is under threat

First, I fear that remote work is a threat to the strength of our local communities. To be clear, I am a fervent proponent of telework for many reasons, not the least of which being that I personally benefit from generous telework policies. I primarily telework, and that option has made a world of difference for me. And I'm not alone. Research shows that the flexibility of telework can improve employees' well-being, job engagement and sense of autonomy.^2,3 Academics and researchers are among the most frequent teleworkers.^4,5 While there is little research focused on investigation academics' and professors' experiences of telework, the findings that are available suggest that telework may improve job satisfaction, work performance, well-being, work–life balance and stress.^6–9 From an organisational perspective, some scholars suggest that flexible telework options may increase the ability to recruit top performing academics because the institution can draw from a broad geographical area.¹⁰

But remote work options has downsides. A recent investigation of academics' experiences of telework found that extensive and/or irregular teleworking could hamper relations between academic colleagues by ‘reducing communication and insight into work processes’.^11(p.16) This drawback is a common topic of conversation in my home. My husband, who is a professor of engineering, has often explained that his office door is a key communication device in his academic life. If the door is shut, he is telling his fellow faculty members (and his students) that he is deep in thought and does not want to be interrupted. If the door is ajar, he is saying that he is available for spontaneous thoughtful conversation, requests for advice or casual chats. The problem with teleworking, he laments, is that his virtual door is always closed. Unless there is a scheduled meeting, people assume he is working and should not be interrupted. Such lack of engagement is a threat to the survival of academic communities broadly and to our local HPE communities specifically. To meet with local colleagues, we need to plan in advance and arrange virtual meetings. And while booking impromptu conversations—that is, ‘let us schedule 15 min for spontaneity’—is truly a contradiction in terms, we need to wrestle with such contradictions to protect the strength of our local community relationships. Eating lunch together, celebrating our life events (e.g. birthdays and awards won), collective grieving (e.g. the grant not received): these are things we used to do together and in person. With telework, we need to schedule time for such moments. Problematically, in a culture of health care, where there is always another patient, another crisis, another project vying for our attention, scheduling time just to catch up is often not a priority.

How our extended communities are under threat

Second, the changing landscape of academic conferences also threatens the strength of our broader HPE communities. Historically, conferences have been sites for community gathering. Research shows that conferences serve important functions in an academic field. For instance, studies have highlighted that being in close proximity with other scholars at academic meetings gives rise to serendipity-based generation of ideas, allows for implicit methodological knowledge to be shared and creates opportunity for latent ideas to be solidified through discussions among experts.¹² In fact, as Regher and I have argued elsewhere, informal conversations at conferences are a powerful means of getting immediate feedback on your latest work or your most pressing problems.¹³ To harness such opportunities, individual scholars often rely on academic conference attendance. Furthermore, at these academic meetings, individual scholars engage with each other ‘not only as researchers who represent intellectual claims, but also as colleagues. In so doing, they attribute not only intellectual statements, but also social identities and roles to one another’.^14(p.922) In summary, conferences are where our HPE community meets, learns from each other and develops relationships that support each of us in the field's network.

But the HPE conference landscape is changing. Academic meetings are increasingly moving to being on-line only or hybrid (with both in-person and online options). This has significant advantages. For instance, online academic meetings can increase accessibility for a wide range of academics including minoritised groups,¹⁵ can decrease the carbon footprint of academia¹⁶ and can promote global inclusivity.¹⁷ But the move to hybrid meetings is problematic for the maintenance of our professional communities. If we know that a key benefit of academic meetings is in spontaneous corridor conversations, how can we have those conversations when there are no corridors? Additionally, the institutions that sponsor HPE's academic meetings are constantly evolving. Some HPE conferences that were once staples of the community's calendar of events have been destabilised because institutional funding priorities have changed. Other meetings are under threat because the sponsoring organisation are facing major budget changes. Given such changes, as members of the HPE field, we need to recognise that the conferences that we have relied on to be the sites of community gathering are actually not stable.

Further complicating matters is the fact that HPE is still a rather young field of inquiry. While some might argue that we are now (or are evolving into) a discipline,¹⁸ we are far from being as stable as a traditional discipline like, for example, chemistry. If chemistry had some conferences that collapsed, that discipline is big enough and robust enough that it could withstand the blows. Yes, there would certainly be impact, but chemistry would persist. I fear that HPE is neither sufficiently large nor robust so as to be impervious to change. We cannot assume that our communities will always have places to gather.

How do we protect our communities

It is easy to stand on the sidelines and say that we need to protect our communities. It is not easy to develop plans for realising that protection. If I had such plans, I'd be a rich woman. I do not, and I am not. But I do have some ideas.

All of these ideas start with one fundamental premise: Our communities require nurturing.

If we can agree on that premise, then the question changes: How can we go about that nurturing work?

Locally, I have taken to using texting as a form of immediate communication with colleagues. I recognise that not everyone is comfortable with that medium (the groan that is met when someone suggests starting a Slack channel is, perhaps, universal). But texting allows us to ask: Is your door closed or ajar? If the recipient responds with ‘closed’, then we can wish them a productive day and move on. But if they respond with ‘ajar’, then we can quickly share a virtual meeting room link for a spontaneous conversation. I also know of colleagues who book full day virtual meetings for writing retreats. They all log in at the beginning of the day, briefly share their writing goals and then leave their cameras (but sound off) on as they work ‘together’ all day. At the end of the day, they share their success (or lack thereof) and log off having had dedicated productive time that was shared with their community. These are just some of the ways that we can bolster the strength of our local communities.

Conclusion

I hope nobody ever finds themselves weeping at their desk because a load of work, with a short deadline, just got dropped on their desk. If it does, I hope you have a community of people you can reach out to for help. But if we do not nurture our communities, I worry that we will not have people (or as many people) to turn to when we are feeling overwhelmed, frustrated and alone. My community is stepping up to help me right now. We need to work to protect and maintain our communities so that, one day, they can step up for you too.

Acknowledgements

REFERENCES

1. Shakespeare, W. The tragedy of hamlet, prince of Denmark. London: The Folio Society, 1954.

2. Delanoeije, J., Verbruggen, M. Between-person and within-person effects of telework: a quasi-field experiment. Eur J Work Organ Psy 2020;29:795–808, 6, https://doi.org/10.1080/1359432X.2020.1774557

3. Charalampous, M., Grant, C.A., Tramontano, C., Michailidis, E. Systematically reviewing remote e-workers' well-being at work: a multidimensional approach. Eur J Work Organ Psy 2019;28:51–73, 1, https://doi.org/10.1080/1359432X.2018.1541886

4. Eurofound and the International Labour Office. Working anytime, anywhere: the effects on the world of work. Luxembourg: Publications Office of the European Union; Geneva, Switzerland: The International Labour Office; 2017.

5. The European Commission's Science and Knowledge Service, Joint Research Centre. Telework in the EU before and after the COVID-19: where we were, where we head to; science for policy briefs. Brussels, Belgium: European Commission; 2020.

6. Currie, J., Eveline, J. E-technology and work/life balance for academics with young children. High Educ 2011;62:533–550, 4, https://doi.org/10.1007/s10734-010-9404-9

7. Tustin, D.H. Telecommuting academics within an open distance education environment of South Africa: more content, productive, and healthy? Int Rev Res Open Dist Learn 2014;15:185–214.

8. Widar, L., Wiitavaara, B., Boman, E., Heiden, M. Psychophysiological reactivity, postures and movements among academic staff: a comparison between teleworking days and office days. Int J Environ Res Public Health 2021;18:9537, https://doi.org/10.3390/ijerph18189537

9. Heiden, M., Widar, L., Wiitavaara, B., Boman, E. Telework in academia: associations with health and well-being among staff. High Educ 2020;81:707–722, 4, https://doi.org/10.1007/s10734-020-00569-4

10. Scagnoli, N. Impact of online education on traditional campus-based education. International Journal of Instructional Technology and Distance Learning 2005;2(10):63–68.

11. Widar, L., Heiden, M., Boman, E., Wiitavaara, B. How is telework experienced in academia? Sustainability 2022;14:57.

12. Kroll H, Neuhäusler P. “Formal and informal networkedness among German academics”: exploring the role of conferences and co-publications in scientific performance. Scientometrics 2022;127: 6431-6452, 11, https://doi.org/10.1007/s11192-022-04526-z

13. Regehr G, Varpio L. Conferencing well. Perspect Med Educ 2022;11:101–103, 2, https://doi.org/10.1007/S40037-022-00704-0

14. Hamann J. The making of professors. Soc Stud Sci 2019;49(6):919-941, https://doi.org/10.1177/0306312719880017

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16. Holden, M. H., Butt, N., Chauvenet, A., Plein, M., Stringer, M., & Chadès, I. Academic conferences urgently need environmental policies. Nat Ecol Evol 2017;1(9):1211–1212, https://doi.org/10.1038/s41559-017-0296-2

17. Fraser, H., Soanes, K., Jones, S. A., Jones, C. S., & Malishev, M. The value of virtual conferencing for ecology and conservation. Conserv Biol 2017;31(3):540–546, https://doi.org/10.1111/cobi.12837

18. Ten Cate, Olle. Health professions education scholarship: the emergence, current status, and future of a discipline in its own right. FASEB Bioadv 2021;3(7):510, 522, https://doi.org/10.1096/fba.2021-00011

Jonathan Sherbino^1,2,3, Linda Snell^3,4, Jason R. Frank^3,5,6 and Lara Varpio^3,7

¹Department of Medicine, McMaster University; ²McMaster Education Research, Innovation and Theory (MERIT) Centre; ³Karolinska Institutet; ⁴Institute of Health Sciences Education, McGill University; ⁵Department of Emergency Medicine, University of Ottawa; ⁶Centre for Innovation in Medical Education, University of Ottawa; ⁷Perelman School of Medicine, University of Pennsylvania

The current era is characterised by growth. Whether the popularity of Dweck's growth mindset,¹ the realisation of Moore's law (the doubling time for computer processing power) or the biomass expansion of our teenagers' laundry hampers, growth has seemingly become the ideal of our theories and trends. For clinicians and educators in health professions education (HPE), there has been a similar growth in journal publications² and in digital education resources.³ But where once there was a garden of organised options that was tended to by journal editors, book publishers and conference planners, there is now unfettered growth. This is certainly an advantage; there is a multitude of resources to choose from, produced by an eclectic variety of thoughtful scholars, and available in many formats. But there are also disadvantages: The learning ecosystem is not managed and so grows untamed, into a veritable educational jungle of learning options, where the canopy begins to obscure the sunlight. The challenge for us, the HPE community, is to support the democratised growth of a wide variety of resources and simultaneously cultivate a garden that facilitates learning.

In this commentary, we argue for effective lifelong learning through accessible, actionable and accountable processes that aid clinicians and educators to navigate a changing and growing learning ecosystem.

Challenges with the learning ecosystem

The destabilisation of traditional journals

Editors suggest that the lingering effect of COVID-19—including a changing scholarly culture where academics reprioritise volunteerism—has increased the challenge of both recruiting reviewers and maintaining quality reviews.

While traditional peer-reviewed journals are struggling, there is the parallel growth of predatory journals⁷ that take advantage of the publication race required of academics to achieve inflated publication metrics for career advancement.⁸ The work of Maggio et al. highlights the explosive rise in publications within HPE.^9,10 McKibbon et al. show a parallel cluttering of the health sciences literature with a number needed to read of 14.¹¹ In other words, for every 14 publications published in top-tier journals (Lancet, New England Journal of Medicine, etc.), only one manuscript will change practice. Thus, readers face the irreconcilable challenge of an explosion of articles to consider with a concomitant delay in accessing high-quality, practice-changing manuscripts.

Academics looking across the learning ecosystem see that traditional journals are struggling to maintain their status as the sites of respected scholarly volunteerism, of peer-reviewed vetting of science and of curated knowledge development. To extend our metaphor, while traditional journals once thrived behind private garden walls with access restricted via gates, those very structures are now recognised as sources of inequity. The traditional educational landscape of journal publications has eroded. Their position of power and authority is being questioned. Meanwhile, new resources have sprouted.

The brambles of digital resources

Today's learning ecosystem now includes a broad spectrum of digital learning resources, as detailed by Trivedi et al.¹² These include blogs and microblogs (e.g. X), podcasts, videos, websites, digital textbooks, apps and more. These emergent media have lowered the threshold costs for production and have widened the circle of contributors in a more democratic fashion. However, digital resources are not without challenges for the clinician and educator seeking to maintain competence. Most of these resources are opportunistic, reflecting the interests of an individual or the perspectives of a grassroots organisation. They rarely comprehensively blueprint and address the scope of related topics in a domain. Moreover, the quality of these new offerings is highly variable. Traditional educational resources prioritised quality standards. (The rigour and process of these standards are open for debate, of course.) In contrast, most digital resources have little, if any, mechanisms of quality assurance. To address these gaps several scoring systems have been developed to provide third-party verification.^13,14 But the explosion of digital educational resources exceeds the capacity of these systems. Finally, as digital resources bloom without the attention of a gardener, issues around identification, searchability and sustained catalogue access become problematic for the clinician and educator. Trivedi et al. suggest that peer influence and local referral, rather than systematic scanning, is the process for identifying a familiar, but not necessarily ‘best’, resource. In other words, resources gain prominence thanks to popular choice, not because the resources themselves are of the highest quality. So, the clinician or educator seeking to learn can easily get lost wandering through a jungle of available resources.

Thus, we have arrived at the problem. A desire to learn, a desire to maintain clinical and academic currency and yet an inability to either access or find a rose among the thorns. In essence, we have decision paralysis.

A solution? Choice architecture

Thaler and Sunstein coined the idea of choice architecture, where the design of an ecosystem influences the choice a person makes.¹⁵ It rests on the basic premise that choices are directly shaped by the context in which the choice is embedded. By structuring options thoughtfully, choice architects can nudge individuals towards better decisions without restricting their freedom. This can involve preferred default options, simplifying complex choices, providing clear, relevant information and leveraging social norms and peer influence.

To consider and engage with the diversity of available learning resources requires both the clinician and the educator to be comfortable with diverse methods and philosophies that inform the resources they encounter. This is not an argument to restrict or prioritise one methodology or paradigm over another. Nor is it an argument to simplify or dumb down the science. Rather, it is a call for more curated series of open-access primers that bring theory, methods and philosophies of science to the forefront, not specifically for the scientists, but for the users of science, that is, clinicians and educators.

The social psychology of learning suggests that individuals have stronger accountability to a group than personal accountability for learning goals.^16,17 Put another way, effective choice architecture introduces social norms and peer influence to motivate a commitment to continuing education. This accountability does not happen via formalised membership in societies or organisations necessarily, but rather as a function of relationships, professional and sometimes personal, that develop in clinical and academic circles. The HPE community can leverage its strong history of social connections to advocate for the development of learning groups. For example, ASME demonstrates this commitment via the Bitesize and MEGABITE events.

Conclusion

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3. Trivedi SP, Rodman A, Eliasz KL, Soffler MI, Sullivan AM. Finding the right combination for self-directed learning: a focus group study of residents' choice and use of digital resources to support their learning. Clin Teach 2024 17:e13722, https://doi.org/10.1111/tct.13722

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6. DeLisi LE. Editorial: where have all the reviewers gone?: is the peer review concept in crisis?. Psychiatry Res 2022; 310. 114454. ISSN 0165-1781. https://doi.org/10.1016/j.psychres.2022.114454

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8. Varpio L, Sherbino J. Demonstrating causality, bestowing honours, and contributing to the arms race: threats to the sustainability of HPE research. Med Educ 2023;58(1):157-163. https://doi.org/10.1111/medu.15148

9. Maggio LA, Costello JA, Norton C, Driessen EW, Artino AR Jr Knowledge syntheses in medical education: a bibliometric analysis. Perspect Med Educ 2021;10(2):79-87. https://doi.org/10.1007/S40037-020-00626-9

10. Maggio LA, Costello JA, Ninkov AB, Frank JR, Artino Jr AR. The voices of medical education scholarship: describing the published landscape. Med Educ 2023;57(3):280-289. https://doi.org/10.1111/medu.14959

11. McKibbon KA, Wilczynski NL, Haynes RB. What do evidence-based secondary journals tell us about the publication of clinically important articles in primary healthcare journals? BMC Med 2004;2:33. https://doi.org/10.1186/1741-7015-2-33, 1.

12. Trivedi SP, Rodman A, Eliasz KL, Soffler MI, Sullivan AM. Finding the right combination for self-directed learning: a focus group study of residents' choice and use of digital resources to support their learning. Clin Teach 2024:e13722. https://doi.org/10.1111/tct.13722

13. Colmers-Gray IN, Krishnan K, Chan TM, Trueger NS, Paddock M, Grock A, Zaver F, Thoma B. The revised METRIQ score: a quality evaluation tool for online educational resources. AEM Educ Train 2019;3(4):387-392. https://doi.org/10.1002/aet2.10376

14. Lin M, Joshi N, Grock A, Swaminathan A, Morley EJ, Branzetti J, Taira T, Ankel F, Yarris LM. Approved instructional resources series: a national initiative to identify quality emergency medicine blog and podcast content for resident education. J Grad Med Educ 2016;8(2):219-225. https://doi.org/10.4300/JGME-D-15-00388.1

15. Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. Connecticut: Yale University Press; 2008.

16. Rumjaun A, Narod F. Social learning theory—Albert Bandura. Science education in theory and practice: an introductory guide to learning theory 2020:85-99, Springer, Cham. https://doi.org/10.1007/978-3-030-43620-9_7

17. Cooke, L.J., Duncan, D., Rivera, L., Dowling S.K., Symonds C., Armson H. How do physicians behave when they participate in audit and feedback activities in a group with their peers?. Implement Sci 13, 104 (2018). https://doi.org/10.1186/s13012-018-0796-8, 1

18. Trivedi SP, Rodman A, Eliasz KL, Soffler MI, Sullivan AM. Finding the right combination for self-directed learning: a focus group study of residents' choice and use of digital resources to support their learning. Clin Teach 2024:e13722. https://doi.org/10.1111/tct.13722