Maria Athina Tina Martimianakis

Academic partnerships between institutions in the Global North (GN) and Global South (GS) are promoted as a strategy to strengthen health systems and build workforce capacity, particularly through health professions education. At the same time, growing calls to decolonize global health partnerships have highlighted persistent inequities in power, knowledge production, and resource distribution that shape how these are enacted. While existing literature often emphasizes technical and outcome-oriented models of collaboration, the relational and processual dynamics that sustain or constrain partnerships in practice have been significantly under-examined. This qualitative study is a postcolonial exploration of academic global health partnerships and how they are experienced and negotiated by those involved. Nineteen participants with experience in long-term partnerships between GN and GS universities were interviewed using semi-structured interviews. Data were analyzed iteratively and thematically, revealing how people, processes, and power shape partnership work. Participants described partnerships as fundamentally relational, sustained by individuals who invested significant emotional and relational effort over time. Partnership processes were iterative and required ongoing negotiation of roles, expectations, and priorities in response to changing contexts. Power operated across relationships and processes, shaping whose expertise was recognized, how decisions were made, and how collaboration unfolded. Participants also described moments in which power was acknowledged, reflected upon, and, at times, resisted in efforts to create more egalitarian partnerships by mitigating systemic colonial practices. These findings suggest that academic global health partnerships are not sustained primarily through formal structures or predefined outcomes, but through the dynamic interplay of people, processes, and power. We introduce the concept of “brain sustain” to reframe health workforce development as a collective, relational, and contextually grounded endeavour. Advancing decolonial and equitable partnerships requires recognition of global, historical, and structural conditions, alongside promotion of the relational and processual work that sustain collaboration.

Introduction: Medical education institutions increasingly employ patient and public engagement (PPE) to inform their learning activities. While this shift is highly welcome, it is equally important to consider whether and how patient and public perspectives have been incorporated in globally influential texts, such as the CanMEDS 2015 Physician Competency Framework, that govern the contexts in which these activities play out, particularly as this framework undergoes revision. Methods: We explored PPE in the creation and revision of CanMEDS, applying textual analysis to an archive that included the current framework, its drafts and revision documents, earlier iterations (e.g. CanMEDS 2005 and 2000) and ancillary texts. We specifically examined patient and public involvement on committees, in expert working groups and in consultation processes. Results: Findings indicate that despite stated desires to include ‘the perspectives of the people who depend on Canadian physicians for their health care’, there was minimal PPE in the 3‐year revision process that led to CanMEDS 2015. Although data on patient and public perspectives were included in the original CanMEDS 2000 framework, these were imported from a provincially focused project from more than 30 years ago. Conclusion: If competency‐based medical education systems wish to realise their promise of meeting societal needs, they must embrace strategies that regularly centre the perspectives of the patients and publics who comprise that society in the design and content of their foundational frameworks. To do so effectively, it may be productive for the field to untangle patient engagement from public engagement and more purposefully apply the wisdom that each of these modalities offers.

Although postgraduate medical education programs in North America have committed to addressing equity, diversity, and inclusion (EDI) issues, learning environment inequities persist and negatively impact learning outcomes. We conducted an exploratory qualitative study to identify mechanisms contributing to ongoing discrimination experiences. We took an intercategorical intersectional approach to conduct a qualitative thematic analysis that focused on unequal social relations as the unit of analysis. Participants were recruited from paediatrics, neurosurgery, and plastic surgery residency training programs. We performed multi-level inductive and deductive coding of semi-structured interviews informed by intersectionality and systemic and aversive racism. 13 participants were interviewed. Participants identified their social identities as marginalized or dominant, and reported intersectional exclusion experiences related to the former that disadvantaged them compared to their peers. Persistent unequal social relations could be mechanistically accounted for by aversive or systemic racism regardless of intersectional identities. Aversive discrimination appeared through performative EDI commitments, microaggressions, and social exclusion. Systemic discrimination contributed to exclusion stemming from the operationalization of cultural norms such as scheduling, social events, and censorship of taboo topics. Participants described variably successful compensatory strategies to overcome their marginalization. Systemic and aversive discrimination contribute to reproducing unequal social relations. Evidence-based approaches exist to address these mechanisms and make learning environments fairer.

Introduction: Clinical learning environments (CLE) are complex and have not been thoroughly explored from the perspective of advancing conceptual understanding of their unique dynamics. An opportunity to advance this understanding rests in examining specific situations, such as what happens when a student/trainee has been involved in a serious patient safety event. Methods: Shaped by concepts of negotiated orders and discourses, we conducted a qualitative, interpretive study in a large urban university and affiliated health science centre in Canada using document analysis and semi‐structured interviews. Documents and interview transcripts were analysed using concepts and tools from Adele Clarke's situational analysis. Results: Between March 2022 and April 2023, we conducted 17 interviews with staff physicians (n = 6), medical residents (n = 2), safety leaders and/or university administrators (n = 9). Analysis revealed counter‐vailing forces that must be constantly interpreted, negotiated and re‐negotiated by participants attempting to deliver on the aspirations of the CLE. Furthermore, analysis revealed potentially competing discourses about the nature of learning in the CLE, animating long‐standing tensions about the role of the CLE in developing clinical expertise and professional identity. Discussion: Our study reveals counter‐vailing forces, interacting policies and potential disagreements about the learning imperatives and priorities of the CLE. These counter‐vailing pressures shape learning about patient safety. More than learning content or process, invested groups must also learn to negotiate risks and responsibilities distributed across multiple social arenas. These distributions are changing. Understanding these dynamics is essential for educators and researchers seeking to positively influence the CLE. Future CLE research should account for the various pressures acting on health service organizations and the possible implications for educational mandates in these spaces.

Purpose: Health advocacy (HA) is a key component of competency frameworks in many global jurisdictions, yet how HA is taught is not well defined, particularly in specialty graduate medical education. This study explored how residents in these programs came to understand what HA is, what activities it entails, and what importance it carries. Method: This qualitative study conducted semistructured interviews of 39 specialty residents from 2 universities (University of Toronto and University of Ottawa) from July 2019 to June 2023. A reflexive thematic analysis was used, with sensitizing concepts of the formal, informal, and hidden curricula and the CanMEDS health advocate role to construct themes from this data set. Results: Most trainees struggled to define what HA means, what good HA should look like, and which kinds of activities it signifies. The lack of definitional clarity meant that many non-HA activities became conflated with HA, particularly research and quality improvement. Few could recall clear formal curricular content, whereas exposure in clinical training environments was highly variable. Many perceived HA activities as threats to clinical efficiency, of little interest to residency program leadership, and of minimal currency in being competitive for eventual staff positions. Self-identified advocates frequently engaged in self-censoring behaviors because they thought their programs and leaders were often not supportive of this kind of work. Conclusions: Trainees struggled to understand what activities comprise HA because it was not prioritized in their programs or they encountered highly variable role modeling. Trainees who participated in HA activities experienced difficulties integrating HA into their overall clinical skill set due to a lack of institutional support. Health advocacy training requires consideration of structural and cultural reinforcements, including the adoption of curricula that integrate it with daily clinical care and address hidden curriculum effects.

International Medical Programmes (IMPs) form a distinctive modality in medical education, with diverse student populations, English as a language of instruction and 'globalized' curricula. A lack of common understanding of IMPs' purposes and role in the medical education landscape triggers critiques. This study aims to document the effects of different discourses used to justify the purpose of IMPs. We use a discourse analysis approach to explore the different ways in which the purposes of IMPs are constructed at the regulatory, institutional, and individual level, and how these discourses interact. The research situates in two IMPs, in the Netherlands and in Hungary. Key-informant interviews, policy documents, and scholarly literature form the archive. The purpose of IMPs is constructed discursively around three distinct narratives and associated practices: around serving the institutions that host them, around serving the (global) public interest, and around serving individual students. Co-existence and misalignments of these three discourses cause conflicting practices and confusion among stakeholders. This study illustrates how diverging perspectives on internationalization in medical education create tensions for learners and staff. Articulating a clear and explicit meaning to internationalization may reduce uncertainties, and may reinforce realistic expectations of what constitutes a good outcome.

Background: Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training. Methods: We conducted a critical narrative review of EDI literature from 2009–2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform. Results: Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI‐related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power. Discussion: Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

The latest edition of "When I say…" offers guidance on what wellness means in Health Professions Education, flagging up the importance of negotiation and engaging key groups for community building.

In the world of wellness, 'burnout' might as well be a God term. But what do we really mean when we say, "I'm burned out." And is this one little word enough?