commentaries digitalas. [Accessed 17 August 2014.] 17 Jehn K, Northcroft G, Neal M. Why differences make a difference: a field study of
diversity, conflict and performance in workgroups. Admin Sci Q 1999;44:741–63. 18 Bohmer R. The Instrumental Value of Medical Leadership:
Engaging Doctors in Improving Services. http://www.kingsfund. orf.uk/leadershipreview. [Accessed 17 August 2014.]
Social networks (and more) are necessary for student and faculty resilience William P Burdick Social networks are recognised increasingly for their effects on behaviours and resilience. If your friends are obese, you are more likely to be obese.1 If your network is strong, you are more likely to recover from adversity in the contexts of human immunodeficiency virus prevention,2 addiction recovery,3 hospital work4 and rural living.5 In addition, social networks have been found to be associated with successful faculty development programmes.6 In this issue, the paper entitled ‘Bridging the gap: the roles of social capital and ethnicity in medical student achievement’ provides evidence that social networks may play a key role in the provision of support for at-risk students.7 The same support from social networks, in addition to other interventions, is needed after graduation when clinicians, educators, health system reformers and other agents of change face adversity. Philadelphia, Pennsylvania, USA
Correspondence: William P Burdick, MD, MSEd, Foundation for Advancement of International Medical Education and Research (FAIMER), 3624 Market Street, 4th Floor, Philadelphia, Pennsylvania 19104, USA. Tel: 00 1 215 823 2232; E-mail: [email protected]
Social networks are recognised increasingly for their effects on behaviours and resilience
Bridging networks are diverse and connect people who may experience different views of the world
However, according to evidence from Vaughn et al. the authors of ‘Bridging the gap’7 among others, social networks are not all created equal. Bridging, or lowdensity, networks are diverse and connect people who may experience different views of the world. High-density or ‘bonding’ networks are important for high efficiency in contexts such as the operating theatre or the battlefield, but don’t necessarily provide opportunities to generate new ideas. Vaughn and colleagues examined the social network structure of under-represented student populations and found that ‘participants who were less homophilous (i.e. were bridging social groups that differed by age and role) more frequently achieved higher grades than their peers’.7 This finding is supported by work that highlights the strength of weak ties,8 and by other work about the importance of low-density social networks for generating new ideas and alternative views of reality.2,9
This burgeoning literature makes it likely that faculty who want to drive change also need robust social networks for resilience. For example, the Foundation for Advancement of International Medical Education and Research (FAIMER) has conducted faculty development programmes around the world since 2001 and has now trained approximately 1000 fellows from 45 countries.10 Fellows plan and implement an education innovation project as a central component of their FAIMER Institute experience. Stories of adversity abound. One fellow had to abandon a research project when the cost of equipment and supplies suddenly became too expensive as her local currency lost value. Another witnessed the overthrow of her government, jeopardising financial support from the public sector for her project and prompting wholesale changes in leadership. For several others, a new dean or head of department with different ideas came to office after the project had been launched.
doi: 10.1111/medu.12607
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 49: 7–20
17
commentaries Finally, one fellow came back to find the school on strike, depriving him of his main Internet access; the school remained on strike for the next 5 months. Faculty who want to drive change also need robust social networks for resilience
In most cases, these fellows rebounded, primarily as a result of the social network created by the fellowship programme. Fellows cite the provision of emotional support from other fellows and ideas from others for alternative pathways to their desired goal as key factors promoting their resiliency.11 The explanation may lie in the fact that our fellowship programmes are designed to promote a balance between a bonded and a bridging social network. Fellows in each cohort come from a dozen or more countries and represent a range of health professions, and thus create a diverse community. At the same time, they form strong bonds as they learn each other’s stories through ‘learning circles’. A blended programme of onsite followed by online engagement maintains connections throughout the 2-year fellowship and after graduation. This type of intentional social network strengthening can be built into other faculty development and student support programmes. Our fellowship programmes are designed to promote a balance between a bonded and a bridging social network
Development of a strong social network is necessary, but we would be remiss to consider this factor in isolation as other elements also need strengthening to enhance resilience. Optimism, persistence, reflective practice, self-efficacy and
18
attention to personal health are undoubtedly important factors.12,13 These characteristics can be learned and nurtured.14–19 Howe et al.20 and Tempski et al.21 propose that these elements of resilience should be taught as part of health professions education. They should also be incorporated into faculty development programmes for agents of change. If we want to build resilient faculty, we need to design faculty development processes that create and enhance social networks comprised of bridging and bonding elements, but we must also create learning environments in faculty development that nurture self-efficacy, advocate reflective practice, promote concepts of personal health, and encourage optimism and grit so that even in the face of challenges and setbacks, change agents can persevere.
7
8
9
10
11
REFERENCES 1 Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357 (4):370–9. 2 Schneider JA, Zhou AN, Laumann EO. A new HIV prevention network approach: sociometric peer change agent selection. Soc Sci Med 2014. doi: 10.1016/j. socscimed.2013.12.034. [Epub ahead of print]. 3 Andrews JA, Tildesley E, Hops H, Li F. The influence of peers on young adult substance use. Health Psychol 2002;21 (4):349–57. 4 Mealer M, Jones J, Moss M. A qualitative study of resilience and posttraumatic stress disorder in United States ICU nurses. Intensive Care Med 2012;38 (9):1445–51. 5 Wells M. Resilience in rural community-dwelling older adults. J Rural Health 2009;25 (4): 415–9. 6 Steinert Y, Naismith L, Mann K. Faculty development initiatives
12
13
14
15
16
17
designed to promote leadership in medical education. A BEME systemic review: BEME Guide No. 19. Med Teach 2012;34 (6):483–503. Vaughan S, Sanders T, Crossley N, O’Neill P, Wass V. Bridging the gap: the roles of social capital and ethnicity in medical student achievement. Med Educ 2015;49:114–23. Granovetter MS. The strength of weak ties. Am J Sociol 1973;78 (6):1360–80. Newman L, Dale A. Network structure, diversity, and proactive resilience building: a response to Tompkins and Adger. Ecol Soc 2005;10 (1):r2. Burdick WP. Global faculty development: lessons learned from the FAIMER initiatives. Acad Med 2014;89 (8):1097–9. Burdick WP, Diserens D, Friedman SR, Morahan PS, Kalishman S, Eklund MA, Mennin S, Norcini JJ. Measuring the effects of an international health professions faculty development fellowship: the FAIMER Institute. Med Teach 2010;32 (5):414–21. Martin AJ, Marsh HW. Academic resilience and its psychological and educational correlates: a construct validity approach. Psychol Sch 2006;43:267–81. Patterson JL, Kelleher P. Resilient School Leaders. Alexandria, VA: Association for Supervision and Curriculum Development 2005. Sloma-Williams L, McDade SA, Richman R, Morahan PS. The role of self-efficacy in developing women leaders. In: Dean DR, Bracken SJ, Allen JK, eds. Women in Academic Leadership. Sterling, VA: Stylus Publishing 2009;50–73. Seligman MEP. Learned Optimism. New York, NY: Random House 1990. Duckworth AL, Gendler TS, Gross JJ. Self-control in school-age children. Educ Psychol 2014;49 (3):199–217. Chaffey LJ, de Leeuw EJ, Finnigan GA. Facilitating students’ reflective practice in a medical course: literature review. Educ
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 49: 7–20
commentaries Health (Abingdon) 2012;25 (3): 198–203. 18 Rakel DP, Hedgecock J. Healing the healer: a tool to encourage student reflection towards health. Med Teach 2008;30 (6):633–5. 19 Singh TS, de Grave W, Ganjiwale J, Supe A, Burdick WP, van der
Vleuten C. Impact of a fellowship programme for faculty development on the self-efficacy beliefs of health professions teachers: a longitudinal study. Med Teach 2013;35 (5):359–64. 20 Howe A, Smajdor A, Stockl A. Towards an understanding of
resilience and its relevance to medical training. Med Educ 2012;46:349–56. 21 Tempski P, Martins MA, Paro HBMS. Teaching and learning resilience: a new agenda in medical education. Med Educ 2012;46:345–6.
Ethnic and social disparities in medical education Christos Lionis There is growing interest in the discussion of issues that affect performance in medical education, but although ethnic and social disparities have become a focus, these factors have not received the attention they warrant. A recent paper from the Netherlands reports that ethnic minority students from non-Western countries demonstrate a significantly lower level of performance and a higher risk for dropout relative to Dutch students.1 Related work demonstrates that such marked ethnicity-related disparities in medical school performance exist even when age, gender, pre-university grade point average and socio-demographic variables are adjusted for.2 O’Neill et al.,3 in a Danish study, reported that neither the type of selection criteria nor the early challenges of medical school appear to play a major role in restricting diversity. However, as interest in evidence relevant to understanding these relationships grows, there remain
Heraklion, Crete, Greece
Correspondence: Christos Lionis, Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, P.O. Box 2208, Crete 71003, Greece. Tel: 00 30 281 039 4621; E-mail: lionis@galinos. med.uoc.gr doi: 10.1111/medu.12609
many controversies and uncertainties surrounding this relatively new domain of research. Marked ethnicity-related disparities in medical school performance exist even when age, gender and other variables are adjusted for
The current issue of Medical Education includes new evidence that derives from Australia,4 the Netherlands5 and the UK.6 All of these studies explore factors that can widen participation in medicine and increase diversity in medical schools by addressing the impacts of home and school socio-economic status (SES) on selection,4 the effects of different selection criteria on student diversity,5 and the impact of relationships on medical student achievement by ethnicity.6 The Australian study4 from Griffin and Hu concluded that to widen participation, it is necessary to focus on selection because testing may have an adverse impact on those from a background of low SES, especially in female students. In the Dutch study5 Stegers-Jager et al. added some evidence indicating that both ethnicity and social background (i.e. being a first-generation university student)
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 49: 7–20
were independent predictors of selection for medical school on academic measures. It is thereby consistent with research from the UK,7 but it is interesting to note that the Dutch study5 found no significant differences among ethnic or social subgroups with respect to failure on nonacademic selection criteria. Testing may have an adverse impact on those from a background of low SES
Finally, the UK survey6 from Vaughn and colleagues brought social network analysis to bear on the question of whether underperformance among certain groups might be caused by social relations and, more specifically, by the tendency to interact with others in the same group as oneself. It reported that students of nonWhite ethnicity often achieved lower grades and that a causal factor might be lower levels of the social capital that mediates interactions with peers, tutors and clinicians.6 The findings of this study should be considered jointly with those of others which suggest that ethnic minority medical students report lack of support, discrimination, isolation and lack
19
Copyright of Medical Education is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
diversity, conflict and performance in workgroups. Admin Sci Q 1999;44:741–63. 18 Bohmer R. The Instrumental Value of Medical Leadership:
Engaging Doctors in Improving Services. http://www.kingsfund. orf.uk/leadershipreview. [Accessed 17 August 2014.]
Social networks (and more) are necessary for student and faculty resilience William P Burdick Social networks are recognised increasingly for their effects on behaviours and resilience. If your friends are obese, you are more likely to be obese.1 If your network is strong, you are more likely to recover from adversity in the contexts of human immunodeficiency virus prevention,2 addiction recovery,3 hospital work4 and rural living.5 In addition, social networks have been found to be associated with successful faculty development programmes.6 In this issue, the paper entitled ‘Bridging the gap: the roles of social capital and ethnicity in medical student achievement’ provides evidence that social networks may play a key role in the provision of support for at-risk students.7 The same support from social networks, in addition to other interventions, is needed after graduation when clinicians, educators, health system reformers and other agents of change face adversity. Philadelphia, Pennsylvania, USA
Correspondence: William P Burdick, MD, MSEd, Foundation for Advancement of International Medical Education and Research (FAIMER), 3624 Market Street, 4th Floor, Philadelphia, Pennsylvania 19104, USA. Tel: 00 1 215 823 2232; E-mail: [email protected]
Social networks are recognised increasingly for their effects on behaviours and resilience
Bridging networks are diverse and connect people who may experience different views of the world
However, according to evidence from Vaughn et al. the authors of ‘Bridging the gap’7 among others, social networks are not all created equal. Bridging, or lowdensity, networks are diverse and connect people who may experience different views of the world. High-density or ‘bonding’ networks are important for high efficiency in contexts such as the operating theatre or the battlefield, but don’t necessarily provide opportunities to generate new ideas. Vaughn and colleagues examined the social network structure of under-represented student populations and found that ‘participants who were less homophilous (i.e. were bridging social groups that differed by age and role) more frequently achieved higher grades than their peers’.7 This finding is supported by work that highlights the strength of weak ties,8 and by other work about the importance of low-density social networks for generating new ideas and alternative views of reality.2,9
This burgeoning literature makes it likely that faculty who want to drive change also need robust social networks for resilience. For example, the Foundation for Advancement of International Medical Education and Research (FAIMER) has conducted faculty development programmes around the world since 2001 and has now trained approximately 1000 fellows from 45 countries.10 Fellows plan and implement an education innovation project as a central component of their FAIMER Institute experience. Stories of adversity abound. One fellow had to abandon a research project when the cost of equipment and supplies suddenly became too expensive as her local currency lost value. Another witnessed the overthrow of her government, jeopardising financial support from the public sector for her project and prompting wholesale changes in leadership. For several others, a new dean or head of department with different ideas came to office after the project had been launched.
doi: 10.1111/medu.12607
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 49: 7–20
17
commentaries Finally, one fellow came back to find the school on strike, depriving him of his main Internet access; the school remained on strike for the next 5 months. Faculty who want to drive change also need robust social networks for resilience
In most cases, these fellows rebounded, primarily as a result of the social network created by the fellowship programme. Fellows cite the provision of emotional support from other fellows and ideas from others for alternative pathways to their desired goal as key factors promoting their resiliency.11 The explanation may lie in the fact that our fellowship programmes are designed to promote a balance between a bonded and a bridging social network. Fellows in each cohort come from a dozen or more countries and represent a range of health professions, and thus create a diverse community. At the same time, they form strong bonds as they learn each other’s stories through ‘learning circles’. A blended programme of onsite followed by online engagement maintains connections throughout the 2-year fellowship and after graduation. This type of intentional social network strengthening can be built into other faculty development and student support programmes. Our fellowship programmes are designed to promote a balance between a bonded and a bridging social network
Development of a strong social network is necessary, but we would be remiss to consider this factor in isolation as other elements also need strengthening to enhance resilience. Optimism, persistence, reflective practice, self-efficacy and
18
attention to personal health are undoubtedly important factors.12,13 These characteristics can be learned and nurtured.14–19 Howe et al.20 and Tempski et al.21 propose that these elements of resilience should be taught as part of health professions education. They should also be incorporated into faculty development programmes for agents of change. If we want to build resilient faculty, we need to design faculty development processes that create and enhance social networks comprised of bridging and bonding elements, but we must also create learning environments in faculty development that nurture self-efficacy, advocate reflective practice, promote concepts of personal health, and encourage optimism and grit so that even in the face of challenges and setbacks, change agents can persevere.
7
8
9
10
11
REFERENCES 1 Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357 (4):370–9. 2 Schneider JA, Zhou AN, Laumann EO. A new HIV prevention network approach: sociometric peer change agent selection. Soc Sci Med 2014. doi: 10.1016/j. socscimed.2013.12.034. [Epub ahead of print]. 3 Andrews JA, Tildesley E, Hops H, Li F. The influence of peers on young adult substance use. Health Psychol 2002;21 (4):349–57. 4 Mealer M, Jones J, Moss M. A qualitative study of resilience and posttraumatic stress disorder in United States ICU nurses. Intensive Care Med 2012;38 (9):1445–51. 5 Wells M. Resilience in rural community-dwelling older adults. J Rural Health 2009;25 (4): 415–9. 6 Steinert Y, Naismith L, Mann K. Faculty development initiatives
12
13
14
15
16
17
designed to promote leadership in medical education. A BEME systemic review: BEME Guide No. 19. Med Teach 2012;34 (6):483–503. Vaughan S, Sanders T, Crossley N, O’Neill P, Wass V. Bridging the gap: the roles of social capital and ethnicity in medical student achievement. Med Educ 2015;49:114–23. Granovetter MS. The strength of weak ties. Am J Sociol 1973;78 (6):1360–80. Newman L, Dale A. Network structure, diversity, and proactive resilience building: a response to Tompkins and Adger. Ecol Soc 2005;10 (1):r2. Burdick WP. Global faculty development: lessons learned from the FAIMER initiatives. Acad Med 2014;89 (8):1097–9. Burdick WP, Diserens D, Friedman SR, Morahan PS, Kalishman S, Eklund MA, Mennin S, Norcini JJ. Measuring the effects of an international health professions faculty development fellowship: the FAIMER Institute. Med Teach 2010;32 (5):414–21. Martin AJ, Marsh HW. Academic resilience and its psychological and educational correlates: a construct validity approach. Psychol Sch 2006;43:267–81. Patterson JL, Kelleher P. Resilient School Leaders. Alexandria, VA: Association for Supervision and Curriculum Development 2005. Sloma-Williams L, McDade SA, Richman R, Morahan PS. The role of self-efficacy in developing women leaders. In: Dean DR, Bracken SJ, Allen JK, eds. Women in Academic Leadership. Sterling, VA: Stylus Publishing 2009;50–73. Seligman MEP. Learned Optimism. New York, NY: Random House 1990. Duckworth AL, Gendler TS, Gross JJ. Self-control in school-age children. Educ Psychol 2014;49 (3):199–217. Chaffey LJ, de Leeuw EJ, Finnigan GA. Facilitating students’ reflective practice in a medical course: literature review. Educ
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 49: 7–20
commentaries Health (Abingdon) 2012;25 (3): 198–203. 18 Rakel DP, Hedgecock J. Healing the healer: a tool to encourage student reflection towards health. Med Teach 2008;30 (6):633–5. 19 Singh TS, de Grave W, Ganjiwale J, Supe A, Burdick WP, van der
Vleuten C. Impact of a fellowship programme for faculty development on the self-efficacy beliefs of health professions teachers: a longitudinal study. Med Teach 2013;35 (5):359–64. 20 Howe A, Smajdor A, Stockl A. Towards an understanding of
resilience and its relevance to medical training. Med Educ 2012;46:349–56. 21 Tempski P, Martins MA, Paro HBMS. Teaching and learning resilience: a new agenda in medical education. Med Educ 2012;46:345–6.
Ethnic and social disparities in medical education Christos Lionis There is growing interest in the discussion of issues that affect performance in medical education, but although ethnic and social disparities have become a focus, these factors have not received the attention they warrant. A recent paper from the Netherlands reports that ethnic minority students from non-Western countries demonstrate a significantly lower level of performance and a higher risk for dropout relative to Dutch students.1 Related work demonstrates that such marked ethnicity-related disparities in medical school performance exist even when age, gender, pre-university grade point average and socio-demographic variables are adjusted for.2 O’Neill et al.,3 in a Danish study, reported that neither the type of selection criteria nor the early challenges of medical school appear to play a major role in restricting diversity. However, as interest in evidence relevant to understanding these relationships grows, there remain
Heraklion, Crete, Greece
Correspondence: Christos Lionis, Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, P.O. Box 2208, Crete 71003, Greece. Tel: 00 30 281 039 4621; E-mail: lionis@galinos. med.uoc.gr doi: 10.1111/medu.12609
many controversies and uncertainties surrounding this relatively new domain of research. Marked ethnicity-related disparities in medical school performance exist even when age, gender and other variables are adjusted for
The current issue of Medical Education includes new evidence that derives from Australia,4 the Netherlands5 and the UK.6 All of these studies explore factors that can widen participation in medicine and increase diversity in medical schools by addressing the impacts of home and school socio-economic status (SES) on selection,4 the effects of different selection criteria on student diversity,5 and the impact of relationships on medical student achievement by ethnicity.6 The Australian study4 from Griffin and Hu concluded that to widen participation, it is necessary to focus on selection because testing may have an adverse impact on those from a background of low SES, especially in female students. In the Dutch study5 Stegers-Jager et al. added some evidence indicating that both ethnicity and social background (i.e. being a first-generation university student)
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 49: 7–20
were independent predictors of selection for medical school on academic measures. It is thereby consistent with research from the UK,7 but it is interesting to note that the Dutch study5 found no significant differences among ethnic or social subgroups with respect to failure on nonacademic selection criteria. Testing may have an adverse impact on those from a background of low SES
Finally, the UK survey6 from Vaughn and colleagues brought social network analysis to bear on the question of whether underperformance among certain groups might be caused by social relations and, more specifically, by the tendency to interact with others in the same group as oneself. It reported that students of nonWhite ethnicity often achieved lower grades and that a causal factor might be lower levels of the social capital that mediates interactions with peers, tutors and clinicians.6 The findings of this study should be considered jointly with those of others which suggest that ethnic minority medical students report lack of support, discrimination, isolation and lack
19
Copyright of Medical Education is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
