谁是医学教育的入侵者?

IF 5.2 1区 教育学 Q1 EDUCATION, SCIENTIFIC DISCIPLINES
Marco Antonio de Carvalho Filho, Megan Milota, Frederic William Hafferty, Ligia Cayres Ribeiro
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Where the impostor phenomenon frames the experience of not belonging as a mistakenly internalised sense of fraudulence, the intruder paradox reframes it as an externally imposed experience of exclusion—especially for those who are seen to deviate from the historically dominant norms of medicine. In doing so, the concept invites us to interrogate the social architecture of medicine itself. Although conceptualised by the authors around the dimension of gender, the intruder paradox concept may inform intersecting processes of <i>othering</i> in medical education.</p><p>So, inspired by this reframing, we offer a provocation: Who, exactly, are the <i>intruders</i> in medical education and practice? And what are the cultural blueprints that ‘culturally clone’ certain kinds of professionals while simultaneously signalling other individuals or groups as outsiders?<span><sup>2</sup></span> We hope this reflection encourages further research into the structural dimensions of non-belonging and exclusion in the medical profession.</p><p>Our central argument is that modern medical education is designed—perhaps unintentionally but nevertheless, structurally—for the success of white, wealthy, subservient, men. This design is not neutral; it is encoded in the rituals, expectations and rhythms of medical training. Let us explore these four dimensions more deeply:</p><p>Medicine, as institutionalised in the West, is a colonial construct. It evolved in parallel with European expansionism, often replacing or suppressing traditional healing practices across the Global South. This coloniality is embedded in and enacted by modern medical professionalism, which continues to privilege Eurocentric values: objectivity, neutrality, emotional detachment and rationality.<span><sup>3</sup></span> These culturally specific values often act as gatekeepers to belonging. Trainees from non-European backgrounds may experience their identities and epistemologies as incompatible with the ‘whiteness’ of medicine—leading not to <i>impostorism</i> in the psychological sense, but to an enforced outsider status, as in the suggested intruder paradox.<span><sup>4, 5</sup></span></p><p>For instance, I, the first author of this commentary, a great-great-child of a traditional healer, vividly remember the first time I was exposed to a conversation about medical professionalism in a North-American conference. Several practices I understood as normal in my cultural context, such as crying during consultations, giving a ride or becoming friends with patients, using the word ‘love’ in the context of professional relationships, were deemed ‘unprofessional’. It took me years to feel empowered to critically reflect and act upon these norms because they are framed as universally relevant, as if there is only one <i>right</i> way of being a doctor: a North-American, North-European way. One of the barriers to challenge this dominant narrative on medical professionalism is the fact that the global academic knowledge debate still excludes global south epistemologies. Often, in English, we are intruders.</p><p>Around the world, medical training is an expensive enterprise. In market-driven education systems, this disproportionately excludes those from working-class or first-generation backgrounds. First, the selection procedures for medical schools often rely on an idea of meritocracy that considers the best candidates the ones who have acquired large amounts of knowledge during high school, privileging students who had the financial and social conditions to afford complementary (often private) education.<span><sup>6</sup></span> Students who had the financial and social security to focus on their studies without the burden of having to contribute to their family incomes. Second, medical schools, in general, demand for full time dedication forcing students to remain economically dependent on their families. This dependence is even worse in countries where higher education is expensive, where student debt is sky rocketing.<span><sup>7</sup></span> Finally, medicine sub-specialisation is increasing the time spent on training, and it is taking longer for young doctors to join the workforce as independent practitioners.</p><p>But the costs are not only financial. The hidden curriculum of medicine is full of social rituals and codes—formal dinners, networking events, language games—that mirror elite social structures.<span><sup>7</sup></span> Trainees not familiar with these rituals, or who feel alienated by them, are marked as different. They are not simply ‘failing to assimilate’; they are being structurally excluded.</p><p>The culture of medicine is profoundly hierarchical. From the outset, students are socialised into a system where conformity is rewarded and questioning authority is punished. This top-down hierarchy produces a culture where being subservient is confused with being professional. Trainees who resist, speak up, or challenge norms are labelled ‘difficult’, ‘not a good fit’ and thus sanctioned as ‘unprofessional’. This is often described as <i>weaponised professionalism</i>—a system where the standards of ‘professional behaviour’ are applied selectively to maintain existing hierarchies and structures of power and privilege, punishing non-conforming attitudes that challenge the status quo.<span><sup>8</sup></span> The result is not just exclusion but delegitimisation. In addition, professionalism can also become nostalgic, as when senior professionals idealise the past, demonise the new generations and actively resist the incorporation of new values in medical culture.<span><sup>9</sup></span> As a consequence, the medical community loses the opportunity to be renewed and refreshed by the <i>intruders</i>.</p><p>Despite the increasing number of women in medical schools around the globe, the structure of the medical career continues to assume the life trajectory of a man. The most intense training years coincide with a woman's reproductive years, often forcing on women an impossible choice between personal and professional aspirations. Residents who become pregnant are still seen as betraying the group, disrupting the team, or lacking commitment—whereas male peers are rarely asked to justify fatherhood.<span><sup>10</sup></span> While not the sole determinant, cultural norms within Western medicine perversely contribute to channelling women into specialties perceived as less prestigious and thus less ‘worthy’. This career structure does not accommodate plural pathways to success, and women are penalised.<span><sup>11</sup></span> This career demands sacrifice, but it is much more intense for a woman. Besides, medicine still reeks of old-fashioned masculinity, with its competitive atmosphere, no pain-no gain work ethos, aggressive communication styles and high prevalence of moral and sexual harassment permeating the career trajectory.</p><p>Taken together, these four dimensions illustrate our argument that the experience of not belonging is less an aberration or individual failing as it is a symptom of a system that was never designed with diversity in mind. The impostor phenomenon asks: <i>Why do I feel like I don't belong?</i> The intruder paradox responds: <i>Because the structure was not built for you</i>. Overestimating the impostor phenomenon as a default conclusion risks holding the individual responsible for a process that is often more structural than psychological. The intruder paradox, however, invites a broader societal critique—one that interrogates the conditions under which belonging is granted, and more importantly, denied.</p><p>As we reflect on these four structural pillars—whiteness, wealth, subservience and masculinity—we recognise that their influence is not universal. They intersect and manifest differently across national, institutional and cultural contexts.<span><sup>5</sup></span> But what they share is a power to invisibly govern who belongs and who is made to feel like an intruder. This is important not only for education but for healthcare in general. Adopting a student-centred education, democratic and participative is the foundational of a person-centred care committed to social justice.</p><p>We invite our readers to consider: Who are the intruders in your institution—and, in turn, who is missing? And what needs to change—in both instances—to ensure that their presence no longer feels paradoxical, but essential? We still have a long way to go in democratising medical education and practice. We all are responsible for this change.</p><p>The authors have no conflict of interest to declare and contribute equally to the conceptualisation and writing of this commentary.</p>","PeriodicalId":18370,"journal":{"name":"Medical Education","volume":"59 10","pages":"1026-1028"},"PeriodicalIF":5.2000,"publicationDate":"2025-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12438021/pdf/","citationCount":"0","resultStr":"{\"title\":\"Who are the intruders in medical education?\",\"authors\":\"Marco Antonio de Carvalho Filho,&nbsp;Megan Milota,&nbsp;Frederic William Hafferty,&nbsp;Ligia Cayres Ribeiro\",\"doi\":\"10.1111/medu.15771\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p>We felt deeply intrigued and inspired by the manuscript that introduces the concept of the <i>intruder paradox</i> as a critical counterpoint to the widely discussed <i>impostor phenomenon</i>.<span><sup>1</sup></span> One of the most compelling contributions of this new concept is that it shifts the locus of the ‘problem’ from the individual psyche (impostor phenomenon) to the social structure within which this psyche is alleged to exist and communicate with both self and others (intruder paradox). Where the impostor phenomenon frames the experience of not belonging as a mistakenly internalised sense of fraudulence, the intruder paradox reframes it as an externally imposed experience of exclusion—especially for those who are seen to deviate from the historically dominant norms of medicine. In doing so, the concept invites us to interrogate the social architecture of medicine itself. Although conceptualised by the authors around the dimension of gender, the intruder paradox concept may inform intersecting processes of <i>othering</i> in medical education.</p><p>So, inspired by this reframing, we offer a provocation: Who, exactly, are the <i>intruders</i> in medical education and practice? And what are the cultural blueprints that ‘culturally clone’ certain kinds of professionals while simultaneously signalling other individuals or groups as outsiders?<span><sup>2</sup></span> We hope this reflection encourages further research into the structural dimensions of non-belonging and exclusion in the medical profession.</p><p>Our central argument is that modern medical education is designed—perhaps unintentionally but nevertheless, structurally—for the success of white, wealthy, subservient, men. This design is not neutral; it is encoded in the rituals, expectations and rhythms of medical training. Let us explore these four dimensions more deeply:</p><p>Medicine, as institutionalised in the West, is a colonial construct. It evolved in parallel with European expansionism, often replacing or suppressing traditional healing practices across the Global South. This coloniality is embedded in and enacted by modern medical professionalism, which continues to privilege Eurocentric values: objectivity, neutrality, emotional detachment and rationality.<span><sup>3</sup></span> These culturally specific values often act as gatekeepers to belonging. Trainees from non-European backgrounds may experience their identities and epistemologies as incompatible with the ‘whiteness’ of medicine—leading not to <i>impostorism</i> in the psychological sense, but to an enforced outsider status, as in the suggested intruder paradox.<span><sup>4, 5</sup></span></p><p>For instance, I, the first author of this commentary, a great-great-child of a traditional healer, vividly remember the first time I was exposed to a conversation about medical professionalism in a North-American conference. Several practices I understood as normal in my cultural context, such as crying during consultations, giving a ride or becoming friends with patients, using the word ‘love’ in the context of professional relationships, were deemed ‘unprofessional’. It took me years to feel empowered to critically reflect and act upon these norms because they are framed as universally relevant, as if there is only one <i>right</i> way of being a doctor: a North-American, North-European way. One of the barriers to challenge this dominant narrative on medical professionalism is the fact that the global academic knowledge debate still excludes global south epistemologies. Often, in English, we are intruders.</p><p>Around the world, medical training is an expensive enterprise. In market-driven education systems, this disproportionately excludes those from working-class or first-generation backgrounds. First, the selection procedures for medical schools often rely on an idea of meritocracy that considers the best candidates the ones who have acquired large amounts of knowledge during high school, privileging students who had the financial and social conditions to afford complementary (often private) education.<span><sup>6</sup></span> Students who had the financial and social security to focus on their studies without the burden of having to contribute to their family incomes. Second, medical schools, in general, demand for full time dedication forcing students to remain economically dependent on their families. This dependence is even worse in countries where higher education is expensive, where student debt is sky rocketing.<span><sup>7</sup></span> Finally, medicine sub-specialisation is increasing the time spent on training, and it is taking longer for young doctors to join the workforce as independent practitioners.</p><p>But the costs are not only financial. The hidden curriculum of medicine is full of social rituals and codes—formal dinners, networking events, language games—that mirror elite social structures.<span><sup>7</sup></span> Trainees not familiar with these rituals, or who feel alienated by them, are marked as different. They are not simply ‘failing to assimilate’; they are being structurally excluded.</p><p>The culture of medicine is profoundly hierarchical. From the outset, students are socialised into a system where conformity is rewarded and questioning authority is punished. This top-down hierarchy produces a culture where being subservient is confused with being professional. Trainees who resist, speak up, or challenge norms are labelled ‘difficult’, ‘not a good fit’ and thus sanctioned as ‘unprofessional’. This is often described as <i>weaponised professionalism</i>—a system where the standards of ‘professional behaviour’ are applied selectively to maintain existing hierarchies and structures of power and privilege, punishing non-conforming attitudes that challenge the status quo.<span><sup>8</sup></span> The result is not just exclusion but delegitimisation. In addition, professionalism can also become nostalgic, as when senior professionals idealise the past, demonise the new generations and actively resist the incorporation of new values in medical culture.<span><sup>9</sup></span> As a consequence, the medical community loses the opportunity to be renewed and refreshed by the <i>intruders</i>.</p><p>Despite the increasing number of women in medical schools around the globe, the structure of the medical career continues to assume the life trajectory of a man. The most intense training years coincide with a woman's reproductive years, often forcing on women an impossible choice between personal and professional aspirations. Residents who become pregnant are still seen as betraying the group, disrupting the team, or lacking commitment—whereas male peers are rarely asked to justify fatherhood.<span><sup>10</sup></span> While not the sole determinant, cultural norms within Western medicine perversely contribute to channelling women into specialties perceived as less prestigious and thus less ‘worthy’. This career structure does not accommodate plural pathways to success, and women are penalised.<span><sup>11</sup></span> This career demands sacrifice, but it is much more intense for a woman. Besides, medicine still reeks of old-fashioned masculinity, with its competitive atmosphere, no pain-no gain work ethos, aggressive communication styles and high prevalence of moral and sexual harassment permeating the career trajectory.</p><p>Taken together, these four dimensions illustrate our argument that the experience of not belonging is less an aberration or individual failing as it is a symptom of a system that was never designed with diversity in mind. The impostor phenomenon asks: <i>Why do I feel like I don't belong?</i> The intruder paradox responds: <i>Because the structure was not built for you</i>. Overestimating the impostor phenomenon as a default conclusion risks holding the individual responsible for a process that is often more structural than psychological. 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引用次数: 0

摘要

我们深深地被手稿所吸引和启发,它引入了入侵者悖论的概念,作为广泛讨论的冒名顶替现象的关键对应物这个新概念最引人注目的贡献之一是,它将“问题”的焦点从个人心理(冒名顶替现象)转移到社会结构中,在这个社会结构中,这种心理被认为存在并与自我和他人交流(入侵者悖论)。冒名顶替者现象将不属于自己的经历框定为一种错误内化的欺诈感,而入侵者悖论将其框定为一种外部强加的排斥体验——特别是对于那些被视为偏离了历史上占主导地位的医学规范的人。在这样做的过程中,这个概念邀请我们质疑医学本身的社会结构。尽管作者围绕性别维度进行了概念化,但入侵者悖论概念可能会影响医学教育中他人的交叉过程。因此,在这种重构的启发下,我们提出了一个挑战:究竟谁是医学教育和实践的入侵者?又是什么样的文化蓝图“在文化上克隆”某些专业人士,同时将其他个人或群体视为局外人?我们希望这一反思能够鼓励对医疗行业中不归属和排斥的结构维度进行进一步的研究。我们的中心论点是,现代医学教育的设计——也许是无意的,但无论如何,从结构上讲——是为了富裕、顺从的白人男性的成功。这个设计不是中性的;它被编码在医学训练的仪式、期望和节奏中。让我们更深入地探讨这四个方面:医学,在西方制度化,是一种殖民建构。它与欧洲扩张主义并行发展,经常取代或压制全球南方的传统治疗实践。这种殖民主义嵌入并由现代医学专业主义制定,它继续赋予欧洲中心价值观以特权:客观、中立、情感超然和理性这些文化特有的价值观往往是归属感的看门人。来自非欧洲背景的受训者可能会觉得他们的身份和认识论与医学的“白”不相容——这不是导致心理意义上的冒名顶替,而是导致强制的局外人地位,正如所建议的入侵者悖论。例如,作为这篇评论的第一作者,我是一位传统治疗师的玄孙,我清楚地记得我第一次在北美会议上接触到关于医疗专业精神的谈话。在我的文化背景下,我认为正常的一些行为,比如在会诊时哭泣、搭便车或与病人成为朋友,在专业关系中使用“爱”这个词,被认为是“不专业的”。我花了很多年才觉得自己有能力批判性地反思这些规范,并根据这些规范采取行动,因为它们被设定为普遍相关的,就好像只有一种正确的医生方式:北美、北欧的方式。挑战这一主导叙事的障碍之一是,全球学术知识辩论仍然排除了全球南方认识论。在英语中,我们通常是入侵者。在世界各地,医学培训是一项昂贵的事业。在市场驱动的教育体系中,这不成比例地排除了工人阶级或第一代家庭背景的学生。首先,医学院的选拔过程往往依赖于精英主义的思想,认为最好的候选人是那些在高中期间获得了大量知识的人,而那些有经济和社会条件负担得起补充教育(通常是私立教育)的学生则享有特权有经济和社会保障的学生可以专注于学习,而不必为家庭收入做出贡献。第二,一般来说,医学院要求学生全职投入,迫使学生在经济上依赖家庭。在那些高等教育费用昂贵、学生债务飙升的国家,这种依赖甚至更严重最后,医学专科化增加了花在培训上的时间,年轻医生作为独立医生加入工作队伍需要更长的时间。但成本不仅仅是经济上的。医学的隐性课程充满了社会礼仪和规范——正式的晚餐、社交活动、语言游戏——反映了精英社会结构不熟悉这些仪式的学员,或者感到被这些仪式疏远的学员,被标记为与众不同。他们不仅仅是“没有被同化”;他们在结构上被排除在外。医学文化有着深刻的等级制度。 从一开始,学生们就融入了一个循规蹈矩得到奖励、质疑权威受到惩罚的社会体系。这种自上而下的等级制度产生了一种文化,在这种文化中,顺从与专业相混淆。那些抗拒、直言不讳或挑战规范的学员会被贴上“难相处”、“不合适”的标签,因此被视为“不专业”。这通常被描述为武器化的专业主义——有选择地应用“专业行为”标准来维持现有的等级制度和权力和特权结构,惩罚挑战现状的不符合标准的态度其结果不仅是排斥,而且是非法化。此外,专业精神也会变得怀旧,如当资深专业人员理想化过去,妖魔化新一代,并积极抵制在医学文化中纳入新的价值观因此,医学界失去了被入侵者更新和刷新的机会。尽管世界各地医学院的女性人数不断增加,但医学职业的结构仍然呈现出男性的生活轨迹。最密集的训练时间正好是女性的生育年龄,这往往迫使女性在个人抱负和职业抱负之间做出艰难的选择。怀孕的居民仍然被视为背叛群体、扰乱团队或缺乏责任感——而男性同伴很少被要求证明自己是父亲虽然不是唯一的决定因素,但西方医学的文化规范反常地导致女性进入被认为不那么有声望的专业,因此不那么“有价值”。这种职业结构不适应通往成功的多种途径,女性受到了惩罚这个职业需要做出牺牲,但对女性来说更强烈。此外,医学界仍然散发着老式的男子气概,竞争激烈的氛围,不求回报的工作精神,咄咄逼人的沟通方式以及贯穿整个职业轨迹的道德和性骚扰的高度流行。综上所述,这四个维度说明了我们的观点,即不归属的经历与其说是一种失常或个人失败,不如说是一个从未在设计时考虑到多样性的系统的症状。冒名顶替现象会问:为什么我觉得自己不属于这里?入侵者悖论的回答是:因为这个结构不是为你而建的。将冒名顶替现象过高估计为默认结论,可能会让个人对一个往往更多是结构性而非心理上的过程负责。然而,入侵者悖论引发了一场更广泛的社会批判——一场对归属被授予,更重要的是,被剥夺的条件的质疑。当我们反思这四个结构支柱——白人、财富、屈从和男子气概——时,我们认识到它们的影响并不普遍。它们在不同的国家、制度和文化背景下相互交叉,并以不同的方式表现出来但他们共同拥有的是一种无形的力量,可以支配谁属于这里,谁会觉得自己像个入侵者。这不仅对教育很重要,对一般的医疗保健也很重要。采用以学生为中心,民主和参与的教育是致力于社会正义的以人为本的护理的基础。我们邀请我们的读者思考:谁是你的机构的入侵者,反过来,谁是缺失的?在这两种情况下,需要改变什么,以确保他们的存在不再是矛盾的,而是必不可少的?在医学教育和实践民主化方面,我们还有很长的路要走。我们都对这一变化负有责任。作者没有利益冲突声明和贡献平等的概念和写作这篇评论。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Who are the intruders in medical education?

Who are the intruders in medical education?

Who are the intruders in medical education?

Who are the intruders in medical education?

We felt deeply intrigued and inspired by the manuscript that introduces the concept of the intruder paradox as a critical counterpoint to the widely discussed impostor phenomenon.1 One of the most compelling contributions of this new concept is that it shifts the locus of the ‘problem’ from the individual psyche (impostor phenomenon) to the social structure within which this psyche is alleged to exist and communicate with both self and others (intruder paradox). Where the impostor phenomenon frames the experience of not belonging as a mistakenly internalised sense of fraudulence, the intruder paradox reframes it as an externally imposed experience of exclusion—especially for those who are seen to deviate from the historically dominant norms of medicine. In doing so, the concept invites us to interrogate the social architecture of medicine itself. Although conceptualised by the authors around the dimension of gender, the intruder paradox concept may inform intersecting processes of othering in medical education.

So, inspired by this reframing, we offer a provocation: Who, exactly, are the intruders in medical education and practice? And what are the cultural blueprints that ‘culturally clone’ certain kinds of professionals while simultaneously signalling other individuals or groups as outsiders?2 We hope this reflection encourages further research into the structural dimensions of non-belonging and exclusion in the medical profession.

Our central argument is that modern medical education is designed—perhaps unintentionally but nevertheless, structurally—for the success of white, wealthy, subservient, men. This design is not neutral; it is encoded in the rituals, expectations and rhythms of medical training. Let us explore these four dimensions more deeply:

Medicine, as institutionalised in the West, is a colonial construct. It evolved in parallel with European expansionism, often replacing or suppressing traditional healing practices across the Global South. This coloniality is embedded in and enacted by modern medical professionalism, which continues to privilege Eurocentric values: objectivity, neutrality, emotional detachment and rationality.3 These culturally specific values often act as gatekeepers to belonging. Trainees from non-European backgrounds may experience their identities and epistemologies as incompatible with the ‘whiteness’ of medicine—leading not to impostorism in the psychological sense, but to an enforced outsider status, as in the suggested intruder paradox.4, 5

For instance, I, the first author of this commentary, a great-great-child of a traditional healer, vividly remember the first time I was exposed to a conversation about medical professionalism in a North-American conference. Several practices I understood as normal in my cultural context, such as crying during consultations, giving a ride or becoming friends with patients, using the word ‘love’ in the context of professional relationships, were deemed ‘unprofessional’. It took me years to feel empowered to critically reflect and act upon these norms because they are framed as universally relevant, as if there is only one right way of being a doctor: a North-American, North-European way. One of the barriers to challenge this dominant narrative on medical professionalism is the fact that the global academic knowledge debate still excludes global south epistemologies. Often, in English, we are intruders.

Around the world, medical training is an expensive enterprise. In market-driven education systems, this disproportionately excludes those from working-class or first-generation backgrounds. First, the selection procedures for medical schools often rely on an idea of meritocracy that considers the best candidates the ones who have acquired large amounts of knowledge during high school, privileging students who had the financial and social conditions to afford complementary (often private) education.6 Students who had the financial and social security to focus on their studies without the burden of having to contribute to their family incomes. Second, medical schools, in general, demand for full time dedication forcing students to remain economically dependent on their families. This dependence is even worse in countries where higher education is expensive, where student debt is sky rocketing.7 Finally, medicine sub-specialisation is increasing the time spent on training, and it is taking longer for young doctors to join the workforce as independent practitioners.

But the costs are not only financial. The hidden curriculum of medicine is full of social rituals and codes—formal dinners, networking events, language games—that mirror elite social structures.7 Trainees not familiar with these rituals, or who feel alienated by them, are marked as different. They are not simply ‘failing to assimilate’; they are being structurally excluded.

The culture of medicine is profoundly hierarchical. From the outset, students are socialised into a system where conformity is rewarded and questioning authority is punished. This top-down hierarchy produces a culture where being subservient is confused with being professional. Trainees who resist, speak up, or challenge norms are labelled ‘difficult’, ‘not a good fit’ and thus sanctioned as ‘unprofessional’. This is often described as weaponised professionalism—a system where the standards of ‘professional behaviour’ are applied selectively to maintain existing hierarchies and structures of power and privilege, punishing non-conforming attitudes that challenge the status quo.8 The result is not just exclusion but delegitimisation. In addition, professionalism can also become nostalgic, as when senior professionals idealise the past, demonise the new generations and actively resist the incorporation of new values in medical culture.9 As a consequence, the medical community loses the opportunity to be renewed and refreshed by the intruders.

Despite the increasing number of women in medical schools around the globe, the structure of the medical career continues to assume the life trajectory of a man. The most intense training years coincide with a woman's reproductive years, often forcing on women an impossible choice between personal and professional aspirations. Residents who become pregnant are still seen as betraying the group, disrupting the team, or lacking commitment—whereas male peers are rarely asked to justify fatherhood.10 While not the sole determinant, cultural norms within Western medicine perversely contribute to channelling women into specialties perceived as less prestigious and thus less ‘worthy’. This career structure does not accommodate plural pathways to success, and women are penalised.11 This career demands sacrifice, but it is much more intense for a woman. Besides, medicine still reeks of old-fashioned masculinity, with its competitive atmosphere, no pain-no gain work ethos, aggressive communication styles and high prevalence of moral and sexual harassment permeating the career trajectory.

Taken together, these four dimensions illustrate our argument that the experience of not belonging is less an aberration or individual failing as it is a symptom of a system that was never designed with diversity in mind. The impostor phenomenon asks: Why do I feel like I don't belong? The intruder paradox responds: Because the structure was not built for you. Overestimating the impostor phenomenon as a default conclusion risks holding the individual responsible for a process that is often more structural than psychological. The intruder paradox, however, invites a broader societal critique—one that interrogates the conditions under which belonging is granted, and more importantly, denied.

As we reflect on these four structural pillars—whiteness, wealth, subservience and masculinity—we recognise that their influence is not universal. They intersect and manifest differently across national, institutional and cultural contexts.5 But what they share is a power to invisibly govern who belongs and who is made to feel like an intruder. This is important not only for education but for healthcare in general. Adopting a student-centred education, democratic and participative is the foundational of a person-centred care committed to social justice.

We invite our readers to consider: Who are the intruders in your institution—and, in turn, who is missing? And what needs to change—in both instances—to ensure that their presence no longer feels paradoxical, but essential? We still have a long way to go in democratising medical education and practice. We all are responsible for this change.

The authors have no conflict of interest to declare and contribute equally to the conceptualisation and writing of this commentary.

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来源期刊
Medical Education
Medical Education 医学-卫生保健
CiteScore
8.40
自引率
10.00%
发文量
279
审稿时长
4-8 weeks
期刊介绍: Medical Education seeks to be the pre-eminent journal in the field of education for health care professionals, and publishes material of the highest quality, reflecting world wide or provocative issues and perspectives. The journal welcomes high quality papers on all aspects of health professional education including; -undergraduate education -postgraduate training -continuing professional development -interprofessional education
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