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Honoring Medicine’s Social Contract: A Scoping Review of Critical Consciousness in Medical Education

Manca, Annalisa MEd; Gormley, Gerard J. MD, FRCGP; Johnston, Jennifer L. PhD, MRCGP; Hart, Nigel D. MD, MMedSc, FRCGP

Author Information
doi: 10.1097/ACM.0000000000003059

Abstract

As medicine’s social contract evolves,1–3 medical schools have a growing obligation to foster physicians who are conscious of social determinants of health, social inequality,4–6 and social dynamics in health care.7 This obligation is reflected in many of the competency and accreditation frameworks that drive current curricula.4,6,8–10 Educators, however, have little information on how to effectively translate these educational goals into teaching activities. The general tendency for the teaching of these topics has been to apply a competency-based approach,11 which tends to focus on the skills that students should possess when they graduate. Some, however, have observed that this approach runs the risk of trivializing a deeper engagement with essential aspects of medical practice.11,12 Scholars have drawn attention to, first, today’s graduates’ lack of awareness of issues such as health inequity and the social determinants of health,13,14 and, second, the need for physicians to take action.15,16 We believe there is an urgent need for contemporary insights into how medical educators can foster students’ understanding of—and action-oriented attitudes toward—social dynamics related to health care. Through developing in graduates an awareness of social determinants of health and an orientation toward action, medical schools and academic institutions may remain socially accountable and lead change even as society—and medicine’s social contract with society—evolve.15,17

Brazilian educational theorist Paulo Freire advocated “critical pedagogy” as a means of empowering people to effect societal change, via “critical consciousness” (i.e., awareness and questioning) of power and privilege.18 This concept is relevant for medical education since, instead of emphasizing competencies or attitudes, critical consciousness focuses on deeper levels of awareness and understanding of social, cultural, historical, and even emotional dynamics.19 For learners, deeper awareness involves moving from a naïve view of the world to a more critical one: that is, a perspective that entails change at personal and political levels. If, collectively, medical educators are truly committed to achieve social responsibility, then an orientation toward critical pedagogy, and, in particular, the fostering of critical consciousness in future doctors, may hold promise for curricular transformation. Incorporating critical pedagogy into medical education requires a nuanced approach, attentive to different contexts and existing pedagogies.20 Indeed, critical pedagogy reminds educators that context is not neutral: “Human beings are because they are in a situation.”18(p109; emphasis in original)

By focusing on how the construct of critical consciousness has, to date, been conceptualized within medical education, this scoping review aims to fill a gap in the literature. The intent is to identify the main elements of critical consciousness in the specific context that is medical education, which, being traditionally more biomedical,21,22 and sufficiently distinct from other health professions education curricula, is worthy of specific focus. In so doing, we aim to help medical educators develop a better understanding of how a critical pedagogy may inform educational strategies. Understanding the specific significance of critical pedagogy in teaching and learning in medical education may leave educators better placed to rigorously theorize and conceptualize its application in interprofessional contexts.

Method

Our research team comprised a medical educationalist (A.M.) and 3 practicing clinical academics (G.J.G., J.L.J., and N.D.H.), all involved in educational research and/or clinical teaching. We undertook a scoping review as per the methodology of Arksey and O’Malley23 and Thomas and colleagues24 outlined below. We chose this particular approach for the synthesis of the literature related to critical consciousness, mapping key concepts25 and summarizing evidence, to convey the breadth and depth of the topic23,26 and identify research gaps in the existing literature.23 In line with the scoping methodology, we did not assess the quality of included articles.26

Identifying the research question

We used the Population, Situation tool,27 developed to help researchers establish questions for qualitative research. In this case, the Population was “undergraduate and postgraduate medical education learners and educators” and the Situation was “application of critical pedagogy constructs, such as critical consciousness, in medical education.” The research question was, therefore, how has critical consciousness been theorized, conceptualized, and fostered within the medical education literature?

Identifying relevant articles

We conducted searches in March 2019 with the assistance of a medical librarian. We searched MEDLINE, EMBASE, PsychINFO, and Web of Science from their inception; that is, we searched the full historical record of each database. See Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A770 for our full search strategy. To ensure inclusion of all articles that were not indexed in the databases or not identified through the main database search, we repeated the search on Google Scholar. We extracted all articles cited in these databases that met the following inclusion criteria:

  • written in English;
  • discussed critical consciousness in undergraduate or postgraduate medical education including continuing professional development;
  • referenced critical pedagogy; and
  • published any time after 1970 (the year of publication of Freire’s seminal book in English18).

Both conceptual and empirical articles were eligible, and we put no limitations on the study design of empirical articles. That is, eligible study designs included qualitative and quantitative methodologies. The single exclusion criterion was a focus on health professions education other than medical. Our search of the 4 databases resulted in an initial sample of 317 articles.

Selecting the articles

After one of us (A.M.) initially scanned the titles and keywords of the 317 articles, we removed 261, deeming them duplicates or not in scope. Next, we retrieved 35 articles from Google Scholar (making 91 articles). Three of us (A.M., J.L.J., and N.D.H.) independently screened the abstracts of all 91 articles, which led to the removal of an additional 60 articles. Next, 2 of us (A.M and N.D.H.) read the remaining 31 articles in full, which led to the deletion of a further 11 that were not in scope. All 4 of us resolved any disagreements at the abstract and full-text screening stages via discussion. Figure 1 illustrates our screening process.

Figure 1
Figure 1:
PRISMA flow diagram66 of a March 2019 search of the literature for articles about critical consciousness or critical pedagogy in medical education. The diagram maps out the number of records identified, included, and excluded at different phases of review and the reasons for their exclusion. Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Charting the data

Two of us (A.M. and N.D.H.) read each article and captured relevant data on a data extraction sheet, which all 4 of us had iteratively developed. Relevant data included demographic, methodological, and theoretical details, such as the aspects or constructs of critical pedagogy that were used, and any theoretical or practical outcomes. See Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/A770 for the full extraction form. Two of us (A.M. and N.D.H.) developed themes collaboratively until no new categories emerged.28(p493) Then, all 4 of us, using the data extraction sheet as a reference, discussed and agreed upon the themes.

Collating, summarizing, and reporting the results

We applied quantitative and qualitative thematic analysis to examine and combine findings from included studies and nonempirical articles.23 We chose this approach because it allowed us to add contextual signposting (i.e., information on the geographical and temporal distribution of the articles) to the qualitative inquiry. Using the information collated in the data chart, we performed a basic numerical analysis of the extent, nature, and distribution of the included articles.23 The main area of scrutiny, which drove our thematic analysis (i.e., the process of “identifying, analysing and reporting patterns [themes] within data”29[p79]), was the use of critical consciousness and underlying theory across included articles. This process of iterative data analysis resulted in the generation of 4 main themes (Table 1).

Table 1
Table 1:
Representation of the Themes Found in Each Article Included in a 2019 Scoping Review on How Critical Consciousness Is Conceptualized in Medical Education, As Interpreted by the Research Team

Results

Nature and distribution of the articles

We included 20 articles in the final selection.17,30–48 None had a quantitative design. Most were case studies (n = 11),17,30–39 1 a literature review,40 and the rest perspective or opinion-based articles (n = 8).41–48 A majority of articles focused on undergraduate medical education (n = 13),17,31–34,37,39–42,44,47,48 3 articles addressed both undergraduate and postgraduate medical education,43,45,46 and 4 addressed continuing medical education (3 on faculty training,30,35,36 1 on physician training38). Seven (first) authors were from the United States,31–33,36,39,43,45 7 from Canada,17,30,35,38,40–42,44,47 2 from the United Kingdom,34,37,48 and 1 from the Netherlands.46 Articles were published between 1999 and 2019; notably, about a third (n = 7) were published between 2017 and 2019.31,36,41,44–47

Major themes

Our thematic analysis revealed 4 major themes: social awareness, cultural awareness, political awareness, and awareness of educational dynamics. To identify the themes, we considered each article’s content by establishing its main purpose with respect to the aspect(s) of the theory (critical pedagogy) that the authors used to underpin their conclusions. Despite some overlap, the themes are situated at different epistemological levels. Two themes (social and political awareness) refer to educational paradigms and pedagogies (i.e., the philosophical basis of educational practices), while the remaining 2 (educational and cultural awareness) refer to educational dynamics and environments (i.e., the actual practices and processes of education). Figure 2 illustrates the relationship among the 4 themes.

Figure 2
Figure 2:
Interaction of 4 themes revealed by a thematic analysis of literature on the construct of critical consciousness as it is conceptualized in undergraduate, postgraduate, and continuing medical education. Despite some overlap, the 4 themes are situated at 2 different epistemological levels: (1) paradigms and pedagogies and (2) educational dynamics and environments.

Social awareness: How medicine is practiced.

This first theme entails the everyday practice of medicine and how medicine interacts with society. Some articles grappling with social awareness in medical education showed how medicine is “conformist,”17,41 which is, in turn, perpetuated by educational approaches that maintain the status quo.42 These approaches, considering students as passive recipients of teachers’ knowledge, are consistent with what Freire identified as the “banking model of education.”18,43 Rejecting the banking model, Freire advocated using education to cultivate critical consciousness as a means to advance social accountability and a disposition toward action in society.18 In the articles we reviewed, the authors who wrote about social awareness advocated the transformation of medicine from a conformist profession to one that promotes social justice.17,41–43 Critical consciousness is central in these articles. Being quite distinct from critical thinking, although complementary to it,30 critical consciousness is conceptualized as a “reflective awareness” of how power, privilege, and inequalities—and also one’s own assumptions and biases—shape social structures.30–33

Some authors have highlighted that students need opportunities to develop “knowledge, skills and, perhaps most importantly, the attitudes, to avoid becoming part of a static and inequitable system of healthcare.”17 According to these authors, educators should support students becoming clinicians who actively empower patients.42 One article suggests that “a critical pedagogical approach could challenge the very premise of medicine by opening up opportunities for students to question the values, assumptions, and epistemologies that underlie and legitimatize it as currently practiced.”40 It also suggests that curricula based on these critical approaches will facilitate students’ understanding of social determinants of health and the effect of sociopolitical inequities on disadvantaged populations. Such curricula also cultivate students’ potential as change agents,33,43 who participate actively and meaningfully in society.40 Importantly, one article highlights that simple teaching on these issues may not be enough to foster students’ orientation to social action; rather, teachers need to show students the “conditions to be challenged and changed.”41 Medical educators should encourage students to consider the sociocultural and political implications of biomedical knowledge and its construction.44 Medical students should “learn with and in the world”45 to develop a critical awareness oriented to action. This learning includes understanding the dynamics of health care systems, contemporary medical research practices,44 and the actors involved in it.

One crucial component of social awareness is the need for faculty to be critically conscious of their own power, within and outside the educational environment.34,43 To illustrate, one author echoes Freire’s constructs:

Encourage medical educators to confront directly the tension between teaching for conformity, which many would argue is key to performing a good and reliable physical examination, and teaching for freedom (or teaching for exploration), which is critical to preparing physicians to question current assumptions, practices, and knowledge.45

Medical school leaders should be socially accountable, embedding critical pedagogy in their schools’ curricula17 in a way that stimulates faculty and other educators to “look for places where power disparities and dehumanization might compromise the mission of medical education,” and, in turn, “find ways to rectify those imbalances.”45 Social awareness is about acknowledging and building upon the challenge of bringing social responsibility effectively into mainstream medical education, which, as DasGupta and colleagues43 note, is not only an issue of content but also of methodology.

Cultural awareness: How cultural “competence” is taught.

This theme refers both to multicultural education practices,30,35 specifically in their relation to power and the distribution of opportunity in society,36 and the need to get beyond teaching cultural “competence.”30–32 In the articles we reviewed, the authors who wrote about cultural awareness considered issues such as postcolonialism37 and the design of international medical electives (IMEs).40

These authors indicated that education for cultural diversity is grounded in critical consciousness of oneself and others.30,37 To illustrate, Schiff and Rieth32 highlight the potential of an elective curriculum that is based on community engagement and the analysis of social determinants of health. They define cultural competence as “knowledge, attitudes, and skills that enable healthcare professionals to communicate with and understand the culturally diverse health beliefs and practices of their patient.”32 Notably, Hanson, Harms, and Plamondon40 warn medical educators that IMEs can reproduce hegemony if the engagement of students from privileged backgrounds is exploitive rather than reciprocal. (Hegemony is a form of power exercised through consent that allows dominant ideologies to be maintained via a “creeping” socialization.49) They remind educators that education is not neutral: it can be domesticating or it can be emancipatory. If educators fail to encourage each student to question and challenge power, then they contribute to and perpetuate students’ acceptance of (and submission to) hegemony.40

The articles advancing the theme of cultural awareness highlight the importance of faculty development in effective educational interventions around gender, race, and socioeconomic class.30,35–37 The absence of skills and a lack of training in facilitating cultural discussions with students can have adverse effects.36 Kumagai and colleagues30,35 describe creating “cognitive disequilibrium” among students, but, in the first place, among educators to prompt their critical reflection and deconstruction of group dynamics during discussions in multicultural education. This technique has helped educators become more aware of not only cultural aspects but also hidden, nonverbal dynamics during small-group discussions; importantly, the technique also provides a means for educators to address these dynamics. Educators’ ability to create a safe educational space and skillfully facilitate cultural discussions is key both to encouraging respectful dialogue around sensitive topics and to fostering an understanding of power and privilege in society.36

Political awareness: How medical education is structured.

Some of the articles addressing political awareness identified hegemonic discourses within the global “industry” of medical education; authors worried about medical education reproducing dominant educational power structures and, in effect, suppressing other, more context-specific, approaches.34,36,38,39,43,46 Political hegemony has the power to limit education to an “industrialised process of production.”49 This understanding of hegemonic discourses in medical education aligns with Freire’s banking model of education,18 which is characterized by a passive acceptance of, or lack of critical thinking around, educational processes.

Authors here advocate for Freirean critical approaches to medical education: that is, developing a critical consciousness of clinical work that “might help to disrupt the unquestioning reproduction of hegemonic medical discourses.”34 Indeed, some of these authors considered medical students’ poor critical awareness to be the result of unquestioned teaching practices, driven by power and network dynamics of pervasive medical discourses and practices.34,39,46 Of course, in today’s complex medical education environment, competency-based medical education (CBME) and validated educational tools, such as problem-based learning, have value both in efficiently distributing knowledge across educational contexts and in aiming to produce qualified and competent doctors.34 Nevertheless, scholars38,46 highlight that particular sociopolitical forces (e.g., conventional methods for institutional evaluations, funders’ demands, national accreditation standards, market forces) contribute to choosing particular educational approaches over others, even if the latter are more context specific.

While emphasizing the need for teachers to critically explore pedagogies and their power,34,43,46,47 authors addressing political awareness also warn that the very structure of medical education largely precludes critical inquiry.39 That is, pursuing critical inquiry within an institution “may paradoxically trigger emotionally distancing reactions and become a barrier to engagement rather than a strength.”20 Nevertheless, we firmly advocate a form of critical inquiry that stems from context-specific needs and works to develop insights into the historical, political, social, and educational environment in which the inquiry itself is embedded. This form of political awareness among teachers and, consequently, students34 counters educational cultural hegemony,34,36,39 promotes transformative learning,36 and encourages “a better balance between the knowledge and power of institutions and professionals, and the knowledge and power of communities.”38 Such critical reflection may induce learners and educators alike to share their personal experiences and voices38; that is, to have courage to speak up and critique institutions and individuals who control power and knowledge.36 In particular, Labonte and colleagues citing Freire and Macedo, remind educators that “the first act of power [that] people can take in managing their own lives is ‘speaking the world,’”38 which, according to Zaidi and colleagues, is itself an act of “breaking away from dominant discourse.”36

Awareness of educational dynamics: How medicine is taught.

Authors covering our last theme, awareness of educational dynamics, addressed conflict,30,34–37,45,47 lack of democracy,30,48 and lack of awareness of power dynamics34,47,48 in medical education. To illustrate, Donetto highlights an intrinsic conflict in educational interventions that aim to encourage reflective practice by applying “pedagogical approaches that prioritize conditioning and habit.”48 Behavioral learning approaches—that is, approaches encouraging students to learn and repeat, almost mechanically, words that portray, for example, empathy or patient-centeredness—are justified within a competency-based discourse.34 However, applying such an approach risks discouraging a deeper understanding of the sociopolitical dimensions of physicians’ professional role.34 Conflict can arise from a mismatch between the didactic teaching delivered to students and what students actually observe in clinical practice.34,37 Another source of dissonance may be the often-binary distinction drawn between the scientific and human sides of medicine and between hard and soft forms of knowledge.34 Even more importantly, there appears to be conflict “between nominally encouraged behaviors” in health care and “the system’s response to their actual enactment.”34

Conflict also arises in students’ reflections and dialogues around the sociocultural issues of diversity, privilege, sexism, and homophobia.30,35,37 Authors highlight that these issues may represent “intensely personal struggles for some students.”30 The key role of teachers, according to authors who addressed awareness of educational dynamics, is not to avoid conflict but, in fact, to highlight contradictions35 and provoke students’ reflection and dialogue. Educators should also identify and elaborate on the sometimes-conflicting norms of their own culture and those of their learners,36 thereby identifying possible unintended consequences of teaching practices.

Discussion

Discourse around critical consciousness is increasing in medical education. Of the 20 articles included in this review, 7 were published in 2017, 2018, and 2019. Although the majority of articles focused on undergraduate medical education, our findings have relevance across contexts since they focus on teaching mindsets and discuss the epistemological roots supporting critical teaching.

In this review, we explore the value of specific theoretical constructs of critical consciousness and critical pedagogy for medical educators. Importantly, however, our intention is not to imply that only curricular changes explicitly labeled critical consciousness or critical pedagogy have value. Many medical education enterprises are aimed at cultivating learners’ understanding of social, cultural, and political contexts of health care and inequities.50–52 Any teaching that focuses on identification of power dynamics, and hence the cultivation of students’ attitude to address inequities, is critical.

A vital question is, how may educators practically apply this construct? We have identified 4 elements of critical consciousness that have philosophical, educational, and methodological significance for medical curricula. We suggest implications for medical education in the paragraphs below and provide practical applications in Table 2.

Table 2
Table 2:
Examples of Practical Applications of Critical Pedagogy Constructs in Medical Curricula

Implications for medical education

Cultivating critical consciousness requires an awareness of how medicine is practiced. That is, medical educators should help learners identify the values, assumptions, and sociopolitical forces shaping the structure of health care and practice and also provide opportunities to question them.47 This process of fostering awareness and critique is oriented toward pragmatic action30,31; that is, it prompts physicians to carry out their social roles and responsibilities,30 becoming agents of change.40 Indeed, the World Health Organization53 asserts that doctors and medical institutions should “direct their education, research and service activities towards addressing the priority health concerns of the community, region, or nation they have a mandate to serve” (emphasis added). Critical consciousness in medical education entails developing educational environments with social accountability at their heart and fostering future doctors who act “first and foremost as health advocates.”54 Medical educators can develop “a pedagogy for social justice that is far reaching, consistent and central to our educational endeavors”43 by creating supportive learning spaces and by encouraging those students who want to be involved with social change and equity.17 In this regard, community participation is key: as students and patients jointly explore health care in real-life contexts, they can, together, identify dynamics and propose solutions to achieve social change.42,45,46 Where local communities work with faculty in a nonhierarchical relationship, community members are empowered to contribute to the shape of the medical curriculum.39

Critical consciousness in medical education requires profound awareness of privilege and sociocultural determinants of health. It also requires awareness of how cultural competence is taught: remaining cognizant of methodologies along with content. Scholars—whether included in this review or not—highlight how training in cultural competence can potentially reproduce hegemony.30,40 The risk is that more privileged students may learn to merely perform desirable behaviors without actually shifting their values,16 therefore assuming an exploitive, rather than reciprocal, attitude toward patients.40 Teaching cultural awareness means not only facilitating students’ knowledge of culturally diverse health beliefs and practices but also, most importantly, helping students recognize and challenge power and privilege.32,40

Medical educators need to become aware of how sociopolitical forces and dominant discourses structure and shape medical education. Becoming critically conscious educators, aware of historical and sociopolitical influences,46 is essential to fostering critical consciousness in learners. Under particular scrutiny is the dominant CBME paradigm.30,31,34,46 Various scholars beyond this review have observed major shortfalls even while acknowledging that CBME standardizes what is considered to be a competent performance.55–60 They argue that medical knowledge becomes a gift “handed down from experienced clinicians to inexperienced trainees,”43 which reinforces the notion that knowledge is more important than the learners themselves.43 Learning is reduced to demonstrating a “series of measurable skills and behaviours,”20,34,46 perhaps to the neglect of vital aspects of practice that “cannot simply be translated into neatly described, measurable competencies.”46 Gaufberg and Hodges61 observed in a recent editorial “a tendency to reduce relational issues in healthcare to an individual competence requiring individual approaches […], while neglecting the influence of systems and culture on relationships.” These forces (e.g., the shift toward CBME) have contributed to a worldwide spread of particular educational models over others, and they have made it difficult to argue for context-specific pedagogies which are better suited to local circumstances.46 There is a growing sense that the pendulum has swung too far toward facts and skills and, therefore, needs to be rebalanced. A rebalancing would involve intentional effort from educators and educational institutions to become critically conscious of their pedagogies. Educators must ask themselves the questions Frambach and Martimianakis have posed: “Where does this training model come from? How did I come to know it? Who benefits or loses, within and beyond my institution, when I use or promote this model?”46

Freire’s theory, as applied to medical education, can help identify and address power discrepancies, while still valuing the contributions of teachers and learners alike. Applying Freire’s critical pedagogy means that educators must step away from their privileged authority, but integrating critical consciousness into medical education will also facilitate change in the culture of medicine by emphasizing nonhierarchical and respectful relationships. Trainees can then translate their experience of these relationships into their clinical care.43 Indeed, clinical educators are vital role models46 in ensuring well-intended educational interventions do not actually reproduce and perpetuate unjust power structures.40 Educators’ own critical awareness in designing and delivering educational interventions ensures that students develop the skills to foster social transformation through self-reflection, critical analysis, and theoretically informed actions.40

This scoping review has value for institutions, educators, and students. The role of institutions as supporting structures in the development of critical consciousness is vital. Many authors of the articles we reviewed stress the importance of faculty development around critical consciousness.30,34–37,43,45 However, there are significant limitations within an institutional setting, especially if such transformative and power-challenging attitudes are not supported at a structural level.20 Applying a critical consciousness approach to competency-based curricula is not straightforward. Critical consciousness and CBME approaches have different philosophical and theoretical underpinnings, which need to be considered to avoid a painful clash of educational content, context, and practices. We share DasGupta and colleagues’ concern regarding the absurdity of teaching social justice as a set of competences, instead of as an integral part of education and medicine.43 The question, however, remains, “How do we effectively assess something that may be conceived as both practice and identity?”62 Although assessing value orientations and motives, rather than skills or behaviors, is challenging, the results may provide a more complete picture.30,62 Educators would need to develop such assessments over time by looking at expressions of critical awareness, such as products of meaningful reflection (e.g., thoughtful discussions or essays), to evaluate whether learners have authentically internalized core values.30,62 Of course, this enterprise would require “major structural and cultural transformations within medical education.”41

Overlapping themes, self-awareness, and compassion

Notably, we acknowledge the degree of overlap that exists among identified themes. Developing educational activities aimed at cultivating one area will invariably touch others. Medical educators must attend to this complexity by avoiding the creation of silos of knowledge or skill. In this vein, we have not associated educational activities with a particular theme in Table 2. Additionally, we believe a “red thread” is running through all 4 themes: self-awareness. Although some authors mentioned the term “self-awareness,”17,30–32,34,35,40,47 the concept was not discussed in depth. Self-awareness is, nonetheless, an important element of critical consciousness—and has the potential to bring compassion to the fore in health care.30 Educators may ask, “How are compassion and critical consciousness connected?” In our view, compassion is a form of deep awareness of one’s own position in the world relative to others.16 Compassion helps learners recognize “the common human condition”63 and respond to others’ needs, transforming, rather than reproducing, current problems.20 Medical students witness potentially emotionally traumatizing events during their clinical years, yet the pedagogic potential of these learning experiences remains largely unaddressed.47 Educators need to be “facile in attending to pain”36 and support students in developing safe, cathartic releases to the strong emotions arising from clinical encounters and other educational experiences. This form of active acceptance and appropriation of one’s own emotions can foster development of the self in relation to others and facilitate a consequent shift in values which enables “authentic compassionate care that confronts societally constructed inequities.”16 Although valuing self-awareness is nothing new, fostering it within students is not straightforward,64 especially within young learners with limited life experience.65 The question of where, then, to focus curriculum change to maximize the effectiveness of critical consciousness is germane. We suggest this as an essential direction for further research.

Limitations

We acknowledge some limitations. In scanning articles initially by titles, abstracts, and subject headings, we may have missed relevant articles. By bounding the search to articles explicitly mentioning “critical consciousness” or “critical pedagogy,” we may have limited the breadth of theoretical models that apply similar critical principles to educational endeavors. We excluded non-English articles, and we acknowledge some key literature may come from other contexts. We did not perform a formal quality assessment of the included articles but have provided here a critical synopsis of findings with implications for practice.

Conclusions

Critical consciousness has been adopted in some medical education arenas as an intellectual construct intended to foster a deep, reflexive awareness of professional power and patient-centered practices amongst students and educators.34,48 Applying critical consciousness approaches to medical education may unearth the epistemologies, values, and biases legitimizing medicine as currently practiced; pose challenges to inequitable health care systems; and foster transformation and social accountability.17,40 Some scholars have highlighted its potential to improve sociocultural responsibility30,32,35,37,40 and to foster compassion in doctors.20,30,32 Notably, bias, inequity, lack of compassion, and too little sociopolitical action are all acknowledged challenges in medical education,4–6 which includes accountability in its social contract.54 Embedding a critical pedagogy approach within medical education may help nurture social accountability by fostering an intrinsic orientation to action in physicians and physicians-in-training alike; however, applying any critical pedagogy requires acknowledging and challenging the current structure and culture of medical education itself.

Acknowledgments:

The authors wish to thank Professor Tim Dornan for the invaluable advice and discussions, Mr. Richard Fallis for his help in performing the literature search, and Dr. Ayelet Kuper for her help in revising the report.

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