By Sophie Soklaridis, PhD, Column Editor
A few weeks ago, I had an interesting conversation with Dr. Morag Paton, one of my colleagues in continuing professional development (CPD). We are on a research project together and Morag had offered to draft a positionality statement, a practice that is becoming more common in academia. Positionality refers to where each one of us is located in relation to our various social identities, which include lived and learned experience, gender, race, ethnicity, sexuality, ability, socio-economic status, geographic location and socio-political history. In academic writing, positionality statements make transparent how our social position influences our scholarly work. They acknowledge that our worldviews (i.e., beliefs, values and interests) influence what we choose to study and teach, our approach to what we study and teach, as well as the methods we use to study and teach. Positionality statements are an important step toward understanding our own social position and our relationship within existing power hierarchies and other systems of oppression.
But how do we take stock of our own position, along with its institutional supports, privileges and limitations? How do we account for our biases? How does our geographical location influence our world view? And furthermore – what impact do these things have on how and what we teach and learn? Does positionality matter if we are teaching, for example, about renal function and physiology? Maybe not, unless the lessons explore certain topics: Why do more women than men have chronic kidney disease? Why do men go into kidney failure sooner than do women? Why are these gender differences still not understood? And why are African-Americans almost four times as likely as white people to develop kidney failure? For nephrology researchers who are trying to understand how renal function intersects with poverty, racism, sexism and other social factors, developing a positionality statement can help them articulate how their work and thinking around these issues becomes an important part of clinical practice, teaching and research.
Have you ever tried to write a positionality statement? If not, try it right now. Here are a few things you can include:
- Identity characteristics, such as age, gender, sexuality, ethnicity, social class, ability, citizenship, religion, immigration status, marital status
- Life experiences, such as previous or current job, volunteer work, membership in societies, advocacy work
- Philosophical, political, theoretical beliefs (how you see the world)
- Your relationships to what you are teaching/studying/developing
Did you feel uncomfortable writing your positionality statement? Maybe it felt a bit weird. Perhaps you felt vulnerable, afraid, uncertain? You’re not alone.
Thinking about our positionality can elicit strong emotional reactions. Going back to that conversation with my colleague, Morag shared a moment during her PhD defense when one of the examiners asked why there wasn’t more feminist theory in her dissertation. Clearly, there was a place for feminist theory, given that her thesis was a Foucauldian-inspired discourse analysis of administrative staff and faculty relations in health professions education. In her dissertation, she engaged with the historical and hierarchical structure of academic medicine vis-à-vis the largely feminized administrative staff. An unexpected sadness started to bubble up within her as she grappled with the examiner’s question and found herself in a disorienting dilemma: her beliefs, values and theoretical perspectives aligned with feminism (in the broadest sense of the term), but in practice (in real life), “being a feminist” was difficult to actualize due to systemic institutionalized sexism. Heavy stuff.
Thinking of our positionality means that we have to wrestle with various systems and forms of oppression (e.g., sexism, racism, elitism, ageism, ableism, homophobia). Why might it be hard or scary to think about them? Simply put, nobody wants to be accused of playing a role in creating and perpetuating oppression. We might be afraid of being blamed for things that happened before our time. Maybe we are ashamed. Or we might feel hopeless because we know what the issues are but feel powerless to do anything about it. Perhaps we are worried that someone might get angry or hurt if we say the wrong thing. Ultimately, we have a hard time thinking about our positionality because we are afraid to talk about inequity.
Understanding where this fear comes from and how to mitigate it could prompt advancement in CPD. It would allow us to create spaces within CPD initiatives where people are safe to feel, acknowledge and talk about fear. This requires a significant shift, especially for health professionals who are expected to be in positions of knowing. Fear is usually rooted in uncertainty and the unknown. Sometimes the perceived risk seems too high, especially when the payoff of these sensitive discussions is unclear (e.g., how do we begin to dismantle racism?). Exploring our uncertainties requires that we be open to vulnerability. When we feel vulnerable, we are actually working from a place of safety and strength. When we are vulnerable, we are likely in some kind of danger. Self-reflection requires us to feel vulnerable.
Which brings us back to positionality statements. Writing a positionality statement requires self-reflection. In health professions education, reflection is a central tenet that helps us to develop expert knowledge and practice. For many health professionals, critical reflectivity is now a core competency within registration standards. Perhaps positionality statements could be a way to begin a conversation about critical reflection. Critical reflection is one of many steps we need to take when we commit to allyship and acting to mitigate inequities. Reflecting on our positionality becomes a form of knowledge production. It can help health professions scholars to find their inner wisdom. It can build community among CPD educators, particularly among scholars who identify as members of equity-deserving groups. Positionality statements can facilitate more open discussions about how oppression and privilege shape the development of CPD scholarship.
These are important discussions for health professionals to have, but they are often met with ambivalence. I’ll give examples using two recent studies I was involved in. The first study implemented a modified version of the R2C2 model, an evidence-based reflective process for providing feedback and coaching through interactive conversations that involves four iterative phases—relationship, reaction, content and coaching (Sargeant et al., 2015). In this yet-to-be-published study, our team modified the model to a competency-based longitudinal ambulatory experience for psychiatry residents. We knew from the existing literature on medical education that evaluators face difficulties in assessing competence independent of gender and gendered expectations. This indicates a gender gap in evaluations of residents’ competency and performance, which in a competency-based framework could be significant. There is also research on gender differences in the qualitative feedback provided to residents. In our modified R2C2 study, we wanted to explore this further, so we added a question about whether power dynamics or any issues around gender, race, ethnicity and other social factors need to be considered during feedback sessions between residents and their supervisors. We asked supervisors: When providing feedback, have you paid attention to the power differences that exist between you and your residents (i.e., staff-student, race, ethnicity, gender, sexuality and socioeconomic status)?
Here is a sample of what supervisors shared with us:
“I think most of the residents I work with are female, I just don’t see it [power] as being relevant to the relationship we have.”
“I’m a white male, and one of the residents was a Black male and one was a white female. I found myself having to reflect more on how to give feedback in a way that would be fair to them or make sense to them.”
“It’s not something you bring up directly with the residents. It might even be a bit of an uncomfortable conversation. And I don’t want to make implications that there’s any issue in terms of gender or race or anything like that.”
This study demonstrated how we all struggle with whether and how to acknowledge and address power dynamics. Perhaps an opportunity for CPD would be to give supervisors strategies for managing power and improving the feedback process (and, of course, for evaluating its implementation and effectiveness).
In our second study, we conducted an environmental scan to see where and how equity, diversity and inclusion (EDI) concepts were taught in physician leadership programs (Soklaridis et al., 2022). We found that most studies did not define equity or provide a theoretical framing around EDI. The curricula in most leadership programs focused on individual attitudes without making the critical connection between personal agency and broader social systems. As long as curricula fail to address the intersection between individuals and the systems in which they operate, efforts to increase diversity in physician leadership will have limited success.
Conceptualizing diversity in CPD also seems like a good opportunity to advance the field. Constance LeBlanc and colleagues (2020) have illustrated the importance of thinking about academic leadership through the lens of intersectionality, which explains how social categories such as race, gender, sexuality and social class converge to produce interlocking systems of oppression and privilege. LeBlanc and colleagues describe their experience at an international conference workshop that examined diversity in medical education and in leadership for medical educators. Participants were asked to picture a president, a CEO or a dean of a medical school. The facilitators then asked whether anyone imagined a person who was female, racially or culturally diverse, or disabled. No one had. This exercise illustrated, quite literally, the magnitude of change required to break not only the status quo, but also our inherent biases.
Some of our colleagues are starting the conversation about structural inequalities and its impact in health professions education. For example, Morag Paton and her colleagues frame contemporary health professions education as the “master’s house,” using a term from civil activist Audre Lorde, who wrote, “the master’s tools will never dismantle the master’s house” (Paton et al., 2020). As Lorde explains, the master’s tools may allow us temporarily to beat him at his own game, but they will never create genuine, lasting change. Paton and colleagues examine the theoretical underpinnings of the master’s house, (using examples of colonialism, racism and sex/gender), explore how these Eurocentric structures may be dismantled, and reflect on the implications and opportunities of this work in praxis.
These conversations about structural inequalities in CPD can’t ignore the COVID-19 pandemic. Scholars have found that equity and diversity are sometimes forgotten in virtual environments (Gordon et al., 2020). We conducted a scoping review of peer-reviewed literature on the academic productivity of physicians from equity-deserving groups during the pandemic to see whether there were articles that moved beyond a gendered analysis (Soklaridis et al., 2023). All the literature we found described the gendered impact on academic productivity, but none provided other demographic characteristics of women (e.g., Black, lesbian, trans). This gap makes it difficult to really understand how structural inequities have affected equity-deserving groups in CPD during the pandemic.
Another important element of equity is accessibility. Our scoping review study found a trend toward a stronger global reach of CPD and the emergence of an era of equitable access to medical education during COVID-19. Some articles described how CPD during the pandemic became more accessible (thus more inclusive) by removing barriers related to time, cost and travel. These articles focused on conferences and reported a significant increase in registration. It is tempting to think that hybrid models might equalize access to CPD around the globe. However, deep down, we all know that unless we challenge entrenched colonialist patterns, we risk deepening inequities in our global partnerships (Büyüm et al, 2020). Just because we can teach/learn virtually does not guarantee that we will not perpetuate and export health professions education that maintains a colonial worldview by disregarding knowledge created outside the Eurocentric norm.
Some articles in our scoping review suggested addressing the equity gap by considering hybrid approaches to CPD and their potential to reduce global warming. A recent editorial in The Lancet described how health professionals are exploring ways to reduce climate change by “decarbonizing” their own practices and advocating systemic change (Kotcher et al., 2021). The authors carve a role for CPD in helping health professionals engage in climate change education and advocacy. Like many of you, I have grappled with the environmental impact of travelling for work. Most of us, though, do not have the expertise in ecology or climatology to contribute to a fact-based argument in this debate (Soosaipillai et al., 2020).
In this column, I have described how positionality statements can strengthen our scholarly work as we reckon with issues of equity, diversity and inclusion in CPD. And although my general message has been to overcome our ambivalence and fear, there might be very good reasons for us to pay attention to those feelings of vulnerability. It is possible that declaring our positionality will come at a steep price. Take a minute and reflect on how you felt earlier when you were drafting your positionality statement. The exercise probably was an emotional one. We need to consider the very real possibility that some scholars are bearing most of the emotional labour when it comes to providing positionality statements. There is also a very real risk that mainstreaming positionality statements further entrenches and disproportionately harms individuals who already face marginalization in health professions education. Our academic environment expects neutrality and objectivity to be standards in rigorous scholarship. But do positionality statements cause harm by further devaluing or marginalizing certain types of scholarship?
We have an excellent opportunity to advance equity in CPD scholarship. As clinical teachers and researchers, we can study/teach/learn how to normalize positionality in health professions education so that all scholars, not only scholars conducting equity scholarship, consider how their identities, backgrounds and professional privileges shape their scholarly activities. We can create mechanisms, systems and examples of positionality statements for our CPD community that take into account and address the potential harm and stigma that may exist when the boundaries between personal and professional become blurred. How we do this without losing the positive aspects that come from unpacking and critically reflecting on our positionality is up to us.
References
Büyüm, A.M., Kenney, C., Koris, A., Mkumba, L. & Raveendran, Y. (2020). Decolonising global health: If not now, when? BMJ Global Health, 5, e003394. http://dx.doi.org/10.1136/bmjgh-2020-003394
Gordon, M., Patricio, M., Horne, L., Muston, A., Alston, S.R., Pammi, M. . . . Daniel, M. (2020). Developments in medical education in response to the COVID-19 pandemic: A rapid BEME systematic review: BEME Guide No. 63. Medical Teacher, 42, 1202–1215. doi: 10.1080/0142159X.2020.1807484
Kotcher, J., Maibach, E., Miller, J., Campbell, E., Alqodmani, L., Maiero, M. & Wyns, A. (2021). Views of health professionals on climate change and health: A multinational survey study. Lancet Planetary Health, 5, e316–e323. https://doi.org/10.1016/S2542-5196(21)00053-X
LeBlanc, C., Sonnenberg, L.K., King, S. &, Busari, J. (2020). Medical education leadership: From diversity to inclusivity. GMS Journal for Medical Education, 37 (2), Doc18. doi: 10.3205/zma001311
Paton, M., Naidu, T., Wyatt, T.R., Oni, O., Lorello, G.R., Najeeb, U. . . . Kuper, A. (2020). Dismantling the master’s house: New ways of knowing for equity and social justice in health professions education. Advances in Health Sciences Education, 25, 1107–1126. doi: 10.1007/s10459-020-10006-x
Sargeant, J., Lockyer, J., Mann, K., Holmboe, E., Silver, I., Armson, H. . . . Power, M. (2015). Facilitated reflective performance feedback: Developing an evidence- and theory-based model that builds relationship, explores reactions and content, and coaches for performance change (R2C2). Academic Medicine, 90, 1698–1706. doi: 10.1097/ACM.0000000000000809
Soklaridis, S., Black, G., LeBlanc, C., MacKinnon, K.R., Holroyd-Leduc, J., Clement, F. . . . Kuper, A. (2023). Academic productivity of equity-deserving physician scholars during COVID-19: A scoping review. Academic Medicine, 98, 123–135. doi: 10.1097/ACM.0000000000004971
Soklaridis, S., Lin, E., Black, G., Paton, M., LeBlanc, C., Besa, R. . . . Kuper, A. (2022). Moving beyond “think leadership, think white male”: The contents and contexts of equity, diversity and inclusion in physician leadership programmes. BMJ Leader, 6, 146–157. doi: 10.1136/leader-2021-000542
Soosaipillai, G., Archer, S., Ashrafian. H. & Darzi. A. (2020). Breaking bad news training in the COVID-19 era and beyond. Journal of Medical Education and Curriculum Development. doi: 10.1177/2382120520938706
Weller-Newton, J.M. & Drummond-Young, M. (2021). Reflective practice in health professions education. In D. Nestel, G. Reedy, L. McKenna & S. Gough (Eds.), Clinical Education for the Health Professions. Singapore: Springer.
Sophie Soklaridis, PhD is a Senior Scientist, Centre for Addiction and Mental Health and Associate Professor, Departments of Psychiatry and Community and Family Medicine, Temerty Faculty of Medicine, University of Toronto
