• Nemesis

Need for critical reflexivity in medical education: The case of ‘contested’ illness and MUS

Improved medical education has frequently been cited as a potential means of improving patient-centred care and increasing patient satisfaction; nowhere does this apply more than within the realm of medically ‘contested’ (stigmatised, politicised, neglected), difficult to treat and/or poorly understood conditions. These conditions are often classified as 'medically unexplained symptoms' (MUS), although 'medically under-investigated' or 'medically under-researched' symptoms might be a more apt term. Recommendations for improving clinical understanding typically and justly focus on biomedical education, and some excellent resources have recently been developed to address this in the field of myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS). In a similar though more high-profile vein, the acknowledged need for a biomedical epistemic hold on Long Covid can be observed in research funding; for example, in February this year the UK National Institute for Health Research (NIHR) announced a £18.5 million investment in predominantly biomedical research. Whilst improved biomedical understanding of specific ‘contested’ or poorly understood illnesses is of course crucial, I do not believe that this alone will fully address more fundamental issues with care of marginalised patient groups across the board.

Increased understanding of contested illnesses as biomedical entities will of course facilitate much-needed medical care and can serve to challenge negative stereotyping and stigma, not least from the application of a highly politicised and ableist biopsychosocial model. However, there will likely always be pathology that is outside of the reach of science and technology, with scientific uncertainty typically resulting in clinical discomfort, in turn leading to psychologisation and/or neglect of patients. Further, even when pathology is understood, local and/or national healthcare policy, macro socio-economic policies, legislation and societal discrimination against certain patient and social groups serve to limit access to appropriate healthcare, add to overall burden of illness and increase disability. Improved biomedical understanding alone will not fully address many implicit (and sometimes explicit) clinical biases arising from perceived social identities of patients, nor will it fully address structural discrimination and inequities. I believe that medical education requires a fundamental re-haul, but this does not have to be as dramatic as it perhaps sounds. A good place to start, in my opinion, is by increasing the emphasis on critical reflexivity in medical curricula and in faculty training.

What is critical reflexivity?

Critical reflexivity has been defined as a process of “recognizing one’s own position in the world in order both to better understand the limitations of one’s own knowing and to better appreciate the social realities of others” (Ng et al., 2019). The qualifier ‘critical’ emphasises an approach which challenges dominant assumptions, norms and discourse, alongside social structures that construct and reinforce power and oppression, privilege and disadvantage. Essentially, critical approaches interrogate ‘knowledge’ that mainstream approaches take for granted, particularly with regards to how power and knowledge are related. Within the context of medical education and practice, critical reflexivity might be understood as an evolving understanding of and sensitivity towards the social positionalities of both healthcare professionals and patients and how such positionalities influence what is known, how it is known and who stands to benefit and be disadvantaged by such knowledge. This understanding in turn requires understanding that individuals’ social positionalities are embedded within a context of social structures and institutions that (re)produce social, health and healthcare inequities.

Thus, critical reflexivity might be considered to encompass but reach beyond reflection, which might be defined as a more individualist endeavour to consider personal assumptions and beliefs within an immediate and personally salient context. Critical reflexivity might also be considered to extend beyond the concept of reflexivity as it is typically used in mainstream social science, the latter term denoting a process whereby individual assumptions, beliefs and biases are considered, but without a broader acknowledgement of the matrix of social structures and power systems within which the individual and others are positioned. Crucially, critical reflexivity is considered transformative, that is, facilitating social change and accountability. This moves far beyond reflective practice which risks being a rather passive endeavour and, within healthcare training, may be largely tokenistic or surveillance-driven.

Critical reflexivity and epistemic justice

Much has been written on epistemic injustice in healthcare (see here and here for seminal papers), and a discussion of this framework is beyond the scope of the blogpost (see here for an overview). Epistemic injustice is notably pertinent within the context of Long Covid; patients with medically ‘contested’ conditions are indubitably more subject to such injustice and this is arguably demonstrated through patient report of clinicians’ disbelief and lack of appropriate models, pathways and services for multi-system, polysymptomatic illness. From this perspective, it is perhaps not surprising that chronic pain and ME/CFS have been discussed through the lens of epistemic injustice in published social sciences and ethics literature and it is surely only a matter of time before Long Covid is given the same treatment.

Critical reflexivity in medical education could be expected to counteract epistemic injustice, in part through acknowledgment of other epistemologies and encouragement of the virtue of epistemic humility. Humility in medicine involves recognising that the biomedical model and underlying positivistic worldview is one way (albeit the dominant way) to understand ourselves and the world around us, that this model and epistemological stance have their limitations and that other epistemological stances may add value to medical practice. Epistemic humility in turn has been proposed as an ingredient which may facilitate more collaborative care partnership. In fact, explicit teaching of epistemic injustice in medical curricula has been proposed; this is a proposal that I support, and one that is highly consonant with the recommendation for a critically reflexive approach to medical education.

In Professor Miranda Fricker’s seminal work on epistemic injustice, she suggests that transitioning from a space of testimonial injustice to that of testimonial justice necessitates an ability to correct for negative identity prejudice, an ability she terms “reflexive critical social awareness”. By reflexive, Fricker explains that in communicating with others, we must be cognizant not only of the social identities of the other party, but also of our own social positioning - thus, turning the lens of scrutiny back on the self. This is essentially reflexivity. Although Fricker’s focus on social power suggests we might also understand this as critical reflexivity, Fricker’s focus is more on individual and interpersonal dynamics (notably social identity prejudice) as opposed to the structural or institutional factors within which social identities are embedded – or constructed, depending on one’s viewpoint. Other theorists have addressed this gap in focusing upon structural epistemic injustices. Structural injustices particularly pertinent to healthcare might include ableist and otherwise discriminatory socio-economic policies in the context of UK welfare reform (and more broadly in the context of OECD countries’ fiscal management through targeting of disabled people) and associated neoliberalist health-related discourse. In medical practice, clinicians’ awareness of structural injustices and how these influence health and healthcare inequities could help counteract epistemic injustice and encourage more equal shared decision-making and constructive patient-doctor relationships.

Critical reflexivity and current medical education provision

In the UK, the General Medical Council and British Medical Association both recognise the need for graduate doctors to be “reflective” practitioners. These organisations also recognise the importance of medical practitioners understanding social determinants or influencers of health, alongside the value of applying knowledge and methods from the social sciences to medical practice. However, practitioner report suggests that medical practitioners are not taught to discuss or assess social determinants of health with patients and there seems very little consensus (or even discussion) of how integration of social sciences into medical curricula might work in practice. Further, emphasis on critically informed approaches (emphasising power relations) and knowledge of structural factors in health and healthcare (including problematical healthcare discourse, political and economic agendas) do not appear to figure amongst graduate training outcomes. Finally, it is not clear what emphasis, if any, there is on understanding the impact of medical students’ and doctors’ own social positionality (rather than the decontextualised social positionality of their patients) upon healthcare practice and provision. As a multiply marginalised patient, my experience has been that there is absolutely no indication of clinicians taking a critically reflexive stance in healthcare encounters. The above-mentioned gaps could arguably be filled by greater emphasis on critical reflexivity in medical education, fostering critically reflexive practitioners as opposed to, at best, reflective practitioners, and structurally competent practitioners as well as culturally competent practitioners. This raises questions about how critical reflexivity might be integrated into medical curricula.

Critical pedagogy and structural competency

Various lenses have been proposed for integrating critically oriented approaches and emphasising critical reflexivity in medical education.

Critical pedagogy, an approach advocated by educational theorist Paulo Freire, underlines the cultivation of ‘critical consciousness’ (awareness and challenging of power and oppression) in both trainers and students with a view to dismantling power hierarchies and facilitating empowerment of marginalised groups. Freire rejected what he called the banking model of education (teachers depositing knowledge in the mind of their students) and promoted a dialogic approach to education. In medical education, this would mean acknowledging and seeking to level out power relations between students and trainers and encouraging students to take a critically informed stance not only to the content of their curricula but also towards trainers’ discourse. Trainers would similarly be required to take a critically reflexive stance toward their training methods, curricula content and underlying assumptions. Such a dialogic and critically informed approach could be an effective way of countering epistemic injustice in healthcare towards marginalised groups, since some research has suggested that negative attitudes of trainers or senior doctors towards certain patient groups might be internalised by medical students. Such an approach might also counter possible epistemic injustice in the student-educator relationship within medical education, particularly where students are members of marginalised groups. Involving patients as educators is also something that has frequently been suggested through the lens of critical pedagogy. Whilst critical pedagogy might be considered a broad-based approach that can be moulded in particular ways, some theorists have developed specific frameworks to increase critically reflexive medical education and practice. One of these frameworks is that of ‘structural competency’.

Structural competency refers an awareness of how social and institutional factors influence healthcare policy, resources and practice and contribute to health outcomes through locating sources of healthcare and health inequalities in factors beyond the individual patient and healthcare professional. The term ‘structure’ can refer to infrastructure, policies, hermeneutical frameworks and even discourse. In this sense, structural competency acknowledges yet moves beyond cultural competency - which acknowledges sociocultural influences in health but tends to locate this within individual. Drs Jonathan Metzl and Helena Hansen, who developed the structural competency framework for medical education, discuss five core skills for this competency framework, including that of structural humility, which might be considered as a form of epistemic sensibility and humility vis-à-vis structural factors impacting on the patient’s health and healthcare. The impact of such structural factors in this regard has elsewhere been described as structural iatrogenesis. In practice, this might mean clinicians taking patients seriously when they locate their struggles in lack of appropriate healthcare, lack of social accommodation, discriminative policies and so on, rather than psychologising or otherwise locating the issue within the individual patient.

A commonality in literature advocating critical reflexivity in medical education is a need for a trans-disciplinary approach. This would indubitably mean drawing from thinking in social sciences and humanities – medical anthropology, sociology, philosophy of medicine and so forth – and also specifically from critically informed thinking such as postcolonial studies and intersectionality. A critically informed approach to medical education would be consistent with Freire’s belief that politics cannot be separated from education or from other social processes, and with the growing movement to decolonise medical curricula.

Long Covid, doctors as patients and critical reflexivity

The unpreparedness on the part of clinical and scientific structures to accommodate the pandemic and - notably – to accommodate Long Covid, alongside the considerable number of doctors who now have Long Covid, appears to be facilitating a move towards critical reflexivity (at least, to some extent).

The phenomenon of doctors as patients is surely playing a role in this shift. Miranda Fricker has pointed out that we try hardest to understand those things that it serves us to, and it has not historically served most medical doctors to understand or empathise with chronic, poorly treated, multi-system illness. With the emergence of Long Covid, of course, this has changed – such illness is now everybody’s concern, including that of medical doctors who now find themselves in the position of patient. This dual positioning is an excellent, albeit rather unfortunate, way of facilitating reflexivity. Many medical doctors are now in a position to reflect personally on the lived experience of chronic, neglected illness, and how they as doctors may have unintentionally impacted detrimentally upon their chronic illness patients through testimonial injustice and complicity with hermeneutical injustice.

The overt failure of health services to accommodate Long Covid also appears to have enforced a form of epistemic humility within medicine, at least relatively speaking. This might be observed in medical literature examining the role of uncertainty (examples here and here) and in media reporting on the inescapability of subjectivity in science. Qualitative research (examples here and here) exploring Long Covid experiences suggests that, whilst some doctors may be quick to psychologise, others are willing to acknowledge that they ‘don’t know’ whilst demonstrating open-mindedness (an epistemic virtue) to emerging research and clinical findings. This appears to be a welcome shift from what long-neglected patient groups have grown accustomed to in healthcare.

As regards critical reflexivity, some research has suggested that the experience of a doctor becoming a patient can create insight into power structures and hierarchies that were previously unknown. This appears to be true for the impact of the pandemic and emergence of Long Covid. Increasingly, medical doctors are acknowledging and challenging both structural and hermeneutical phenomena in healthcare that discriminate against multi-system, polysymptomatic chronic illnesses, and also pre-existing structural inequities which disproportionately render marginalised groups susceptible to healthcare discrimination and poor health outcomes. It is worth noting that all these issues have been raised repeatedly pre-pandemic by long-neglected and profoundly marginalised patient groups, and yet such groups have historically been largely ignored. Had a critically reflexive stance been integrated into medical education (and broader health sciences training) pre-pandemic, perhaps the healthcare system would have been better able to accommodate Long Covid, whilst the harms and losses sustained by historically marginalised patient groups - many of which are irreparable - could have been avoided.

The insights afforded by ‘doctor as patient’ status may be accompanied with the realisation that many doctors have previously been (unintentionally) complicit with oppressive structures in a way that has been detrimental to patients. Whilst such realisations can be painful and create cognitive dissonance, they can also prove fruitful by effectuating changes in clinical behaviour and attitudes to resolve that dissonance. It is perhaps unsurprising that some research has suggested that compassion can be fostered through doctors having experiences as patients, findings hypothesised to be related to critical reflexivity. Development of compassion through fostering of critical consciousness (even without doctors having experiences as patients) is also well discussed in published literature. This again points to the value of integrating critical reflexivity into medical curricula.

To conclude, critical reflexivity involves attending to micro and macro processes, individual and structural level phenomena, that facilitate the privileging of certain epistemologies and narratives over others, with a view to countering hegemonic discourse in a way that is socially transformative. I believe that this is also key to countering epistemic injustice within ‘contested’ illness healthcare. Long Covid offers an opportunity to work to benefit all marginalised patient groups, if medical doctors (particularly those with Long Covid) are able to turn the reflexive lens back onto themselves and onto the power structures within which they practice. Without critical reflexivity, we are reduced to chopping down the weeds of inequity without removing the roots - and hoping they don’t grow back.