Is it just me? Everyday sexism- and racism in medical school : experiences, explanations, and strategies among medical students

Background: Medical education is characterized by unequal conditions for women/men and white/racialized students. Even subtle interactional processes of inclusion and exclusion convey messages about who rightfully belongs in medical school. Insights into these processes, though, are scarce – especially in the Swedish context. In this thesis, the concepts ’everyday sexism/racism’ and ’gendered/racial microaggressions’ serve as a theoretical framework for understanding these processes. Aim: The main objective of this thesis is to explore and analyze how medical students experience, understand, and handle the norms, perceptions, and expectations about gender and culture/ethnicity that are expressed and (re)created in the specific contexts of medical education and clinical practice. In the analysis, a particular focus is placed on power inequalities. The role that the image of Sweden, which is characterized by equality, and the notion of medical education as characterized by objectivity and neutrality play in the participants' understanding and actions is discussed. Method: The four articles that make up this thesis are based upon three empirical studies conducted among medical students at Umeå University.  In the first study, focus groups were performed with 24 students (15 women, 9 men) to explore their experiences of situations during clinical training where they perceived that gender mattered. The material was explored using qualitative content analysis.  In the second study, 250 students’ written answers to two short essay questions were analyzed to explore the impact of medical school experiences on specialty preferences. Utilizing a sequential mixed methods design, their responses were analyzed qualitatively to create categories that thereafter were compared quantitatively between men and women.  In the third study, generating two articles, individual interviews were conducted with 18 students (10 women, 8 men) who self-identified as coming from cultural or ethnic minority backgrounds, exploring their experiences of interactions related to their minority position. Inspired by constructivist grounded theory, data collection and analysis were iterative. Findings and reflections: In individual interviews and focus groups, many participants initially described the medical school climate as equal and inclusive. Still, in their narratives about concrete experiences they gave another picture. In interactions with supervisors, staff, and patients almost everyone had regularly encountered stereotypes, discriminatory treatment, and demeaning jargon. Simultaneously, a subtle favoring of male and white majority students was noted. Thus, values, norms, and hierarchies concerning gender and culture/ethnicity were crucial dimensions in their narratives. These experiences made female students feel like they were rendered invisible and not taken seriously, and marked racialized minority students’ status as ’Others’ – making both female- and minority students feel less worthy as medical students. However, most were unsure whether they could call their experiences “sexist”, ”racist”, or ”discriminatory”. Instead, they found other explanations for people's actions such as curiosity, fear, or ignorance.  Participants strove to manage the threat of constraining stereotypes and exclusion while maintaining an image of themselves as professional physicians-to-be. They opposed being seen – and seeing themselves as – problematic and passive victims. The clinical power hierarchy, fear of repercussions, and lack of support from bystanders affected what modes of action seemed accessible. Consequently, participants tended to stay silent, creating emotional distance, and adapting to avoid stereotypes rather than resisting, confronting, and reporting unfair treatment.  The school climate also had consequences for specialty preferences. Both women and men expressed that working tasks and potential for work-life balance were motifs for their specialty preference. These aspects, however, were often secondary to feeling included or excluded during clinical practice. More women than men had been discouraged by workplaces with perceived hostile or sexist climates. In contrast, more men had been deterred by specialty knowledge areas and what they thought were boring work tasks.  Conclusions: Medical students experience everyday sexism- and racism or microaggressions, i.e., practices that, intentionally or inadvertently, convey disregard or contempt. However, the contemporary discourse, which confines sexism and racism into conscious acts perpetrated by immoral or ignorant people, and the pretense that these phenomena no longer pose a problem in Sweden or in medical school, obscure their structural and systemic nature. In fact, this limited view of sexism and racism leaves inequities normalized and disempowers those targeted by discrimination.  Constraining stereotypes and exclusion are not caused by the actions of their recipients, that is, female or racialized/minority students. Consequently, their behavioral changes like avoidance and adaptation will not eliminate discrimination but, instead, tend to re-establish the white male medical student as the norm. As long as students who do not fit the norm, rather than the norm itself are regarded as the problem, the sexist and racist practices described in this study will remain part of the hidden curriculum and part of the process of becoming and being a physician. Simultaneously, formal commitments to equality are at risk of being only symbolic while inequities persist.  To counteract these inequities, the medical community needs to acknowledge female and racialized medical students’ knowledge about sexist and racist practices within our institutions. Further, medical school leadership should provide students, supervisors, and teachers with an account of structural and everyday sexism and racism, encourage them to engage in critical self-reflection on their roles in sexist and racist power relations, and with strategies and training on how to intervene as bystanders and allies.

Is it just me? Everyday sexism- and racism in medical school : experiences, explanations, and strategies among medical students

Background: Medical education is characterized by unequal conditions for women/men and white/racialized students. Even subtle interactional processes of inclusion and exclusion convey messages about who rightfully belongs in medical school. Insights into these processes, though, are scarce – especially in the Swedish context. In this thesis, the concepts ’everyday sexism/racism’ and ’gendered/racial microaggressions’ serve as a theoretical framework for understanding these processes. Aim: The main objective of this thesis is to explore and analyze how medical students experience, understand, and handle the norms, perceptions, and expectations about gender and culture/ethnicity that are expressed and (re)created in the specific contexts of medical education and clinical practice. In the analysis, a particular focus is placed on power inequalities. The role that the image of Sweden, which is characterized by equality, and the notion of medical education as characterized by objectivity and neutrality play in the participants' understanding and actions is discussed. Method: The four articles that make up this thesis are based upon three empirical studies conducted among medical students at Umeå University.  In the first study, focus groups were performed with 24 students (15 women, 9 men) to explore their experiences of situations during clinical training where they perceived that gender mattered. The material was explored using qualitative content analysis.  In the second study, 250 students’ written answers to two short essay questions were analyzed to explore the impact of medical school experiences on specialty preferences. Utilizing a sequential mixed methods design, their responses were analyzed qualitatively to create categories that thereafter were compared quantitatively between men and women.  In the third study, generating two articles, individual interviews were conducted with 18 students (10 women, 8 men) who self-identified as coming from cultural or ethnic minority backgrounds, exploring their experiences of interactions related to their minority position. Inspired by constructivist grounded theory, data collection and analysis were iterative. Findings and reflections: In individual interviews and focus groups, many participants initially described the medical school climate as equal and inclusive. Still, in their narratives about concrete experiences they gave another picture. In interactions with supervisors, staff, and patients almost everyone had regularly encountered stereotypes, discriminatory treatment, and demeaning jargon. Simultaneously, a subtle favoring of male and white majority students was noted. Thus, values, norms, and hierarchies concerning gender and culture/ethnicity were crucial dimensions in their narratives. These experiences made female students feel like they were rendered invisible and not taken seriously, and marked racialized minority students’ status as ’Others’ – making both female- and minority students feel less worthy as medical students. However, most were unsure whether they could call their experiences “sexist”, ”racist”, or ”discriminatory”. Instead, they found other explanations for people's actions such as curiosity, fear, or ignorance.  Participants strove to manage the threat of constraining stereotypes and exclusion while maintaining an image of themselves as professional physicians-to-be. They opposed being seen – and seeing themselves as – problematic and passive victims. The clinical power hierarchy, fear of repercussions, and lack of support from bystanders affected what modes of action seemed accessible. Consequently, participants tended to stay silent, creating emotional distance, and adapting to avoid stereotypes rather than resisting, confronting, and reporting unfair treatment.  The school climate also had consequences for specialty preferences. Both women and men expressed that working tasks and potential for work-life balance were motifs for their specialty preference. These aspects, however, were often secondary to feeling included or excluded during clinical practice. More women than men had been discouraged by workplaces with perceived hostile or sexist climates. In contrast, more men had been deterred by specialty knowledge areas and what they thought were boring work tasks.  Conclusions: Medical students experience everyday sexism- and racism or microaggressions, i.e., practices that, intentionally or inadvertently, convey disregard or contempt. However, the contemporary discourse, which confines sexism and racism into conscious acts perpetrated by immoral or ignorant people, and the pretense that these phenomena no longer pose a problem in Sweden or in medical school, obscure their structural and systemic nature. In fact, this limited view of sexism and racism leaves inequities normalized and disempowers those targeted by discrimination.  Constraining stereotypes and exclusion are not caused by the actions of their recipients, that is, female or racialized/minority students. Consequently, their behavioral changes like avoidance and adaptation will not eliminate discrimination but, instead, tend to re-establish the white male medical student as the norm. As long as students who do not fit the norm, rather than the norm itself are regarded as the problem, the sexist and racist practices described in this study will remain part of the hidden curriculum and part of the process of becoming and being a physician. Simultaneously, formal commitments to equality are at risk of being only symbolic while inequities persist.  To counteract these inequities, the medical community needs to acknowledge female and racialized medical students’ knowledge about sexist and racist practices within our institutions. Further, medical school leadership should provide students, supervisors, and teachers with an account of structural and everyday sexism and racism, encourage them to engage in critical self-reflection on their roles in sexist and racist power relations, and with strategies and training on how to intervene as bystanders and allies.

I am a human and I am a human that killed someone : A qualitative study on reconciliation and mediation

There has been an increase in the deadly violence with firearms and with that an increase in drug dealing. Because of that politicians have toughed up the debate on how to deal with it, where longer and harder punishments seem to be the way to go. The persons who are most likely to get caught up in the violence are men in the ages 15-29 years old, where not only drugs are the main reason, but also the socioeconomic- and demographic differences in our country will be a factor. The retributive justice system is still the dominating one, but reparative justice is getting bigger within Sweden too, it’s just not yet on the same level as in other countries. The purpose of this thesis was to know more about the experiences and challenges that the professionals have that work with reconciliation and mediation. A qualitative method with semi structured interviews has been used to interview two professionals working at Försoningsgruppen and two professionals working at Medlingsverksamheten in Lund. To analyze the results I used theories about shame, guilt, the other and theories about moral and empathy. The results from the interviews showed that to be able to reconcile, the person who has done wrong needs to be able to feel guilt and to take on genuine and full responsibility for their actions. It also showed that the person that has done wrong needs to take on a new identity, an identity of both being a human and a human that has done harm to another person. They need to become the other, and that is one hard thing to accept

Platsbaserat lärande och dess roll i SO-undervisning

Syftet med studien är att undersöka hur lärare i lågstadiet ser på platsens betydelse för inlärning, men även hur de arbetar med det, framför allt i SO-undervisning. Syftet har även varit att se vad forskning och läroplan säger om platsbaserat lärande som undervisningsmetod. Vi har använt oss av en kvalitativ metod, där fem lärare i årskurserna 1-3 på tre olika skolor har intervjuats. Resultatet visar att lärarna vi intervjuat ser fördelar med att använda platsbaserat lärande i undervisningen. De menar att det är en undervisningsmetod som gynnar många och genom att gå utanför klassrummet får eleverna använda sig av sinnena, fantasin och praktisk inlärning. Detta betonar även teoretiker så som Dewey, Key, Montessori och Vygotskij är viktigt för inlärning. Resultatet visar även att lärare använder sig av platsbaserat lärande men i olika utsträckning. En viktig faktor till att lärarna kan använda sig av denna undervisningsmetod hänger på att skolan avsätter pengar till läromedel som finns utanför skolan. Detta har varierat på de skolor vi besökt och bidragit till att arbetssättet har använts i olika utsträckning

Platsbaserat lärande och dess roll i SO-undervisning

Syftet med studien är att undersöka hur lärare i lågstadiet ser på platsens betydelse för inlärning, men även hur de arbetar med det, framför allt i SO-undervisning. Syftet har även varit att se vad forskning och läroplan säger om platsbaserat lärande som undervisningsmetod. Vi har använt oss av en kvalitativ metod, där fem lärare i årskurserna 1-3 på tre olika skolor har intervjuats. Resultatet visar att lärarna vi intervjuat ser fördelar med att använda platsbaserat lärande i undervisningen. De menar att det är en undervisningsmetod som gynnar många och genom att gå utanför klassrummet får eleverna använda sig av sinnena, fantasin och praktisk inlärning. Detta betonar även teoretiker så som Dewey, Key, Montessori och Vygotskij är viktigt för inlärning. Resultatet visar även att lärare använder sig av platsbaserat lärande men i olika utsträckning. En viktig faktor till att lärarna kan använda sig av denna undervisningsmetod hänger på att skolan avsätter pengar till läromedel som finns utanför skolan. Detta har varierat på de skolor vi besökt och bidragit till att arbetssättet har använts i olika utsträckning

"I have to do twice as well" – managing everyday racism in a Swedish medical school

Background: Mounting evidence suggests that medical students from cultural/ethnic minority backgrounds face recurring and more or less subtle racist oppression, i.e., everyday racism. Insights into how they handle these inequalities, though, are scarce – especially in a Swedish context. In this interview study we therefore explored and analyzed the strategies used by racialized minority medical students to manage episodes of everyday racism – and their underlying motives and considerations. Methods: Individual interviews were carried out with 15 medical students (8 women, 7 men) who self-identified as having ethnic- or cultural minority backgrounds. Inspired by constructivist grounded theory, data were collected and analyzed simultaneously. Results: Participants strove to retain their sense of self as active students and professional future physicians – as opposed to passive and problematic ‘Others’. Based on this endeavor, they tried to manage the threat of constraining stereotypes and exclusion. Due to the power relations in medical education and clinical placement settings as well as racialized students’ experience of lacking both credibility and support from bystanders, few dared to speak up or report negative treatment. Instead, they sought to avoid racism by withdrawing socially and seeking safe spaces. Or, they attempted to adopt a professional persona that was resistant to racial slights. Lastly, they tried to demonstrate their capability or conform to the majority culture, in attempts to refute stereotypes. Conclusions: Racism is not caused by the exposed individuals’ own ways of being or acting. Therefore, behavioral changes on the part of minority students will not relieve them from discrimination. Rather, strategies such as adaptation and avoidance run the risk of re-inscribing the white majority as the norm for a medical student. However, as long as racialized minority students stand alone it is difficult for them to act in any other way. To dismantle racism in medical education, this study indicates that anti-racist policies and routines for handling discrimination are insufficient. School management should also acknowledge racially minoritized students’ experiences and insights about racist practices, provide students and supervisors with a structural account of racism, as well as organize training in possible ways to act as a bystander to support victims of racism, and create a safer working environment for all

Impostor phenomenon and its association with resilience in medical education – a questionnaire study among Swedish medical students

Abstract Background Concern over medical students’ well-being is a global issue, with studies showing high psychological distress rates. Impostor Phenomenon (IP), i.e., underestimating one’s abilities, attributing success to external factors, and feeling like a fraud, has been implicated as one reason behind these troubling findings. Meanwhile, resilience has been suggested to protect against psychological distress. This study aimed to investigate the prevalence of IP and its association with resilience among undergraduate medical students. Methods The Clance Impostor Phenomenon Scale (CIPS), the Brief Resilience Scale (BRS), and sociodemographic questions were completed by 457 medical students registered in their 2-10th semester at a Swedish university. Of the respondents, 62.6% identified as women, 36.1% as men, and 1.3% as others. Results The prevalence of IP was 58.4% (defined as CIPS score ≥ 62). According to the CIPS scoring guidelines, 10.3% of participants had low IP, 29.5% moderate, 41.6% frequent, and 18.6% intense IP. Of all participants, almost 90% experienced at least moderate and 60.2% frequent to intense IP. Women had significantly higher CIPS scores and lower BRS scores than men. In contrast, neither attending semester nor age group significantly impacted CIPS scores. Finally, there was a moderate inverse correlation between the level of resilience and the prevalence of IP. Conclusions Our findings suggest that the majority of Swedish medical students feels like an impostor, and of these students, most do so frequently. Furthermore, IP is more prevalent among female students – who also show lower levels of resilience. Moreover, our results indicated that IP could hinder achieving higher resilience. Future longitudinal studies should investigate how gender norms may contribute to IP feelings and explore the potential advantages of counteracting IP and strengthening resilience among medical students. However, targeted interventions addressing individual students’ IP and resilience are insufficient. There is also a need to address structural aspects of the educational environment, such as gender stereotypes, that may contribute to IP

Emotional intelligence among medical students in Sweden – a questionnaire study

Abstract Background Emotional intelligence (EI), the ability to understand and regulate one’s and other’s emotions, has been linked to academic and clinical performance and stress management, making it an essential skill to develop during medical school. Nevertheless, uncertainty remains about the impact of medical education on EI, its association with sociodemographic factors, and the potential moderating role of gender. Therefore, this study aimed to explore levels of global EI among Swedish medical students based on their completed semesters while analyzing the potential moderator role of gender and identifying potential EI differences associated with age, gender, prior education, work experience, and previous experience working in a leadership position. Methods The participants were medical students in semesters 1, 3, 5, 7, 9, and 11 at a Swedish University. Participants answered the self-report Trait Emotional Intelligence Questionnaire - Short Form (TEIQue-SF) and demographic questions. For each participant, the mean global trait EI was calculated (range 1–7), and differences were compared based on semesters and sociodemographic factors. In addition, we investigated the relationship between semester and EI scores with gender as a moderator. Results Of the 663 invited medical students, 429 (65%) responded, including 269 women (62.7%), 157 men (36.6%), and 3 identifying as others (0.7%). The participants had a mean global trait EI score of 5.33. Final-year students demonstrated significantly higher global trait EI scores than first-year students, and gender did not have a moderating effect across semesters. Furthermore, students in the age group 25–29 years showed higher EI scores compared to those in the age group 21–24 years, while there were no significant differences in EI scores for older students (≥ 30 years) compared to other age groups. Higher EI scores were also positively associated with previous work-and leadership experiences. Gender and previous education did not significantly impact EI scores. Conclusions Our findings suggest that higher EI scores are associated with semesters of medical education, age, and previous work and leadership experience. Future longitudinal studies are needed to identify factors that could improve EI among medical students to design curricular activities aimed at supporting the EI of the next generation of physicians

The accuracy of digital templating in cementless total hip arthroplasty in dysplastic hips

Background: Total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH) is a complex procedure due to associated anatomical abnormalities. We studied the extent to which preoperative digital templating is reliable when performing cementless THA in patients with DDH. Methods: We templated and compared the pre- and postoperative sizes of the acetabular and femoral components and the center of rotation (COR), and analysed the postoperative cup coverage, leg length discrepancy (LLD), and stem alignment in 50 patients (56 hips) with DDH treated with THA. Results: The implant size exactly matched the template size in 42.9% of cases for the acetabular component and in 38.2% of cases for the femoral component, whereas the templated ±1 size was used in 80.4 and 81.8% of cases for the acetabular and femoral components, respectively. There were no statistically significant differences between templated and used component sizes among different DDH severity levels (acetabular cup: p = 0.30 under the Crowe classification and p = 0.94 under the Hartofilakidis classification; femoral stem: p = 0.98 and p = 0.74, respectively). There were no statistically significant differences between the planned and postoperative COR (p = 0.14 horizontally and p = 0.52 vertically). The median postoperative LLD was 7 (range 0–37) mm. Conclusion: Digital preoperative templating is reliable in the planning of cementless THA in patients with DDH

Experiences of the gender climate in clinical training – a focus group study among Swedish medical students

Abstract Background Research shows that medical education is characterized by unequal conditions for women and men, but there is a lack of qualitative studies investigating the social processes that enable and maintain gender inequalities that include both male and female students. In this focus group study, we therefore explored male as well as female medical students’ experiences of the gender climate – i.e., how beliefs, values, and norms about gender were communicated – during clinical training and how the students dealt with these experiences. Methods Focus group interviews were conducted with 24 medical students (nine men) at Umeå University, Sweden. The interviews were structured around personal experiences in clinical training where the participants perceived that gender had mattered. Data were analysed using qualitative content analysis. Results The students described gender-stereotyped expectations, discriminatory treatment, compliments, comments, and demeaning jargon. Female students gave more personal and varied examples than the men. The students’ ways of handling their experiences were marked by efforts to fit in, for example, by adapting their appearance and partaking in the prevailing jargon. They felt dependent on supervisors and staff, and due to fear of repercussions they kept silent and avoided unpleasant situations and people rather than challenging humiliating jargon or supervisors who were behaving badly. Conclusions Everyday communication of gender beliefs combined with students’ adaptation to stereotyped expectations and discrimination came across as fundamental features through which unequal conditions for male and female students are reproduced and maintained in the clinic. Because they are in a dependent position, it is often difficult for students to challenge problematic gender attitudes. The main responsibility for improvements, therefore, lies with medical school leadership who need to provide students and supervisors with knowledge about gendered processes, discrimination, and sexism and to organize reflection groups about the gender climate in order to improve students’ opportunities to discuss their experiences, and hopefully find ways to protest and actively demand change