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Finding Potential in Balance: Navigating the Competing Discourses of Diversity and Standardization

Schrewe, Brett MDCM; Frost, Heather PhD

doi: 10.1097/ACM.0b013e31826d56ca
Response to the 2012 Question of the Year

Dr. Schrewe is a clinical educator fellow, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada.

Dr. Frost is a postdoctoral fellow, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada.

Correspondence should be addressed to Dr. Schrewe, Suite 3300, 910 West 10th Ave., Vancouver, BC, Canada V5Z 1M9; telephone: (604) 875-4111, ext. 69128; e-mail:

The 2012 Question of the Year highlights an intriguing tension in medical education regarding the place of the individual in the context of the profession. This tension arises, we believe, from the presence of two dominant yet conflicting discourses: the discourse of diversity and the discourse of standardization. We suggest that in order to more effectively ensure that those who work and learn in medical schools and teaching hospitals can develop to their full potential, these competing discourses must be made explicit and brought into a single conversation so that we might take advantage of the tension arising between them.

The discourse of diversity emphasizes a respect for individual learners, their cultures, their genders, and their ethnicities. For example, in describing “Diversity 3.0,” Nivet1 writes that “medical schools and teaching hospitals are shifting their strategies to better capture, leverage, and respond to the rich diversity of human talents and aptitudes.” He further suggests that “promoting diversity must be tightly coupled with developing a culture of inclusion, one that fully appreciates the differences of perspective.” Perhaps this discourse is best evidenced by emerging policies around medical schools’ admissions processes, in which schools increasingly seek students with a multiplicity of backgrounds and life experiences.

At the same time, this valuing of difference is in tension with another dominant discourse in medical education, one that underscores uniformity, consistency, and commonalities throughout the profession. Consider, for example, the persistent and growing push for the integration of competency frameworks, such as CanMEDS, into all levels of medical training. Inherent in this discourse is a drive to define concretely what every physician should be, what each should be able to do, and the knowledge and skill sets that each should master. This homogenizing tendency is also embedded within scholarly conversations with regard to certification and professionalism, as well as the ongoing debate around medical identity formation. Further, this discourse resonates with Western medicine’s tradition of apprenticeship, where novices, in becoming experts, eventually come to adopt many of the practices and attitudes of the preceding generation that trained them.

Therefore, while one discourse concerns itself with engendering a culture of plurality, where individual abilities and experiences are considered important assets, the other—through its emphasis on standardization, consistency, and quality control—focuses its energies on defining the core values and practices common to every physician and, by extension, the profession as a whole. Viewed separately, each of these discourses is sensible and has laudable goals. Their objectives, however, are at odds such that in narrowly pursuing the goals of one we may inadvertently undermine those of the other. This current landscape has resulted in frustration for faculty and mixed messages for learners. Given these confusing circumstances, it is not surprising that it is challenging for learners to realize their full potential.

As each of these discourses confers benefits to individual learners as well as the educational community as a whole, our purpose is not to resolve the tension by suggesting that the field simply privilege one to the detriment of the other. Rather, in exposing these competing discourses, we seek to make that tension explicit and capitalize upon the potential value derived from addressing both discourses simultaneously. In so doing, we hope to open the possibility of forging a new pathway that acknowledges the need for professional standardization, competency, and a shared sense of what it is to be a physician, while at the same time encouraging medical learners to take advantage of their unique perspectives. Such an approach would invite educators to consider how they might guide learners to actively engage this tension as they endeavor to form a professional identity: in other words, how they might adopt the values, traditions, and standards of the profession while concurrently striving to maintain and incorporate their individuality.

Choosing this admittedly challenging path invites us to critically and continually reflect upon other, unarticulated questions. Cardinal among these is: Which common qualities make us physicians and to what extent can individual variation around these qualities be supported before the very essence of the profession begins to dissipate? Such questions are unnerving. We would suggest, however, that it is only in purposively grappling with these unsettling questions that the profession can begin to better enable each and every member of the community to achieve his or her full potential.

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1. Nivet MA. Commentary: Diversity 3.0: A necessary systems upgrade. Acad Med. 2011;86:1487–1489
© 2012 Association of American Medical Colleges