Enacting a Counterspace to Advise TLM’s Global Diversity, Equity, and Inclusion Effort

Until very recently, Teaching and Learning in Medicine (TLM) maintained a poor record of publishing scholarship conducted outside of the United States (U.S.), Canada, and a small number of countries in Western Europe. Although bibliometric studies show a broad trend of geographically based inequity in medical education publishing,^1,2 TLM was one journal consistently found near the bottom of charts reporting global representation of publication authors.¹ TLM also has lagged historically in global representation on the editorial board,³ with no members affiliated with institutions outside the U.S. and Canada until very recently. I (ATC) can easily recall writing decision letters to authors in China, India, and Saudi Arabia, among so many other countries, that exacerbated the leaky pipeline of publications⁴ from what is known as the Global South.⁵

Although you have made a strong effort, the written English in this manuscript is very hard to understand. We recommend you collaborate with a colleague fluent in English or make use of an affordable, reputable editing service.

The topic of your study is clearly of local importance, but its relevance to TLM readers is not so clear.

In the summer of 2020, as our editorial board began to reckon with inequity within U.S. academic structures—disparities in access to publishing in particular—attention turned also to our failure to live up to our moniker “An International Journal.” At one of the board meetings assembled to design our anti-racism strategy,⁶ a member located in the U.S., but born and trained in India (Subha Ramani, MBBS, PhD), called out our participation in the unjust structures affecting global representation among our publications’ authors. Other board members who shared Dr. Ramani’s lived experience of geographically based academic inequity and a passion for improving access to publishing (e.g. Senthil Kumar Rajasekaran, PhD, Zareen Zaidi, MD, PhD) reached out to me (ATC) to brainstorm ideas for acting on this insight. The Global Counterspace Program (GCP) was born out of their initiative and TLM’s ensuing effort to (1) understand the barriers to publication experienced by scholars in the Global South; (2) recognize our complicity in sustaining the existence of these barriers; and (3) take steps, with advisement from GCP members, to dismantle these barriers—at TLM and beyond.

A counterspace may be seen as a community setting in which marginalized individuals challenge “deficit-oriented dominant cultural narratives and representations concerning these individuals,”^{7, p. 261} thereby facilitating their “capacity to circumvent, resist, counteract and/or mitigate the psychological consequences of oppression.”^{7, p. 261} In these communities, “proactive attempts are made to ensure that patterns of oppression in the larger societal context are not reproduced within the [community] setting.”^{7, p. 259} The role of counterspaces in countering epistemic oppression in medical education has been envisioned,⁸ but not yet (to our knowledge) attempted. Establishing this community was an organizing committee comprising the following TLM board members:

• Senthil Kumar Rajasekaran, MD, MMHPE – Professor of Medicine and Vice Dean for Medical Education, Khalifa University College of Medicine and Health Sciences, United Arab Emirates – TLM Review Board Member

• Zareen Zaidi, MD, PhD – Professor Internal Medicine, George Washington University, USA – former TLM Deputy Editor

• Anabelle Andon, MA, PhD – Medical Education and Learning Specialist, Columbia University Vagelos College of Physicians and Surgeons, USA – TLM International Editor

• Saniya Sabzwari, MD, MHPE – Professor Family Medicine, Aga Khan University, Karachi, Pakistan – TLM Deputy Editor

• Thirusha Naidu, PhD – Associate Professor, Department of Behavioral Medicine, University of Kwazulu-Natal, South Africa – TLM Global Diversity, Equity, and Inclusion Editor

Each member of the organizing committee was selected among enthusiastic volunteers from our editorial board for having lived experience with academic inequity and having a past or current residence in a Global South country. Though I (ATC) was fully supportive of this effort, I was intentionally excluded as a core member of the organizing committee to avoid accidental reproduction of oppressive patterns within the group’s activities and discussions.⁷

GCP members were recruited via a competitive application process. To seek applicants, the organizing committee partnered with the Foundation for Advancement of International Medical Education and Research (FAIMER), looked to its fellow TLM editors and reviewers, and reached out to personal networks. Finalists were selected for their demonstrated commitment and clear interest in issues of decolonization in medical education.⁹ The resulting group comprises 26 individuals who represent at least 46 countries and collectively speak 15 different languages. Together, they have 391 years of experience in health professions education and have published more than 1260 papers.

The inaugural meeting was held in March 2022, with the following scholars comprising the GCP, listed in alphabetical order:

• Eusang Ahn, MD, MSc (MedEd), Dipl.KSEM, FRCPC, Emergency Physician, Medical Education Clinical Fellow, Department of Emergency Medicine, The Ottawa Hospital - University of Ottawa, Canada

• Elize Archer, PhD (HPE), Associate Professor, Center for Health Professions education, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa

• Soha Ashry, MD, DHPE, DTQM, Head of Medical Education Department, Professor of Clinical Toxicology, Faculty of Medicine – Ain Shams University, Egypt

• Komal Atta, MBBS, MPhil (Physiology), MME, AFAMEE, Director, Department of Medical Education, University Medical and Dental College, The University of Faisalabad, Pakistan

• S. Ayhan Çalışkan, MD, PhD, Department of Medical Education, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE

• Catherine Danielle R. Duque-Lee, MD, MMHA, MSc, FPAFP, Family and Community Medicine Residency Training Officer, Ospital ng Makati, Philippines

• Irene Durante, MD, MBA Professor, Postgraduate Division in Medicine, School of Medicine, UNAM, Mexico

• Bibi Sumera Keenoo, MBBS, MSc, MD, MHPE, Department of Medicine, Faculty of Medicine and Health Sciences, University of Mauritius

• Young-Mee Lee, MD, MSED, PhD, Professor Department of Medical Education Korea University College of Medicine, Seoul South Korea. Former Editor in Chief, Korean Journal of Medical Education

• Peih-ying Lu, PhD, Professor of Medical Humanities, College of Medicine; Dean of College of Humanities and Social Sciences, Kaohsiung Medical University, Taiwan

• Michan Malca-Casavilca, MD, Professor, Medical School, Peruvian University of Applied Sciences (UPC), MSc Candidate, Faculty of Medicine, National University of San Marcos (UNMSM)

• Brahmaputra Marjadi, MD, MPH, PhD, SFHEA, FPHAA, Associate Professor in Community Engaged Learning, School of Medicine, Western Sydney University, Campbelltown, NSW, Australia

• Sowbhagya Micheal, PhD, FHEA, Lecturer in Medical Education, School of Medicine, Western Sydney University, Campbeltown, New South Wales, Australia

• Hyunmi Park, MBChB, FRCS, PhD, Associate Professor, Department of Medical Education, Korea University College of Medicine, Seoul, South Korea

• P. Ravi Shankar, MD, Faculty, IMU Center for Education, Kuala Lumpur, Malaysia

• Wunna Tun, MBBS, MSc, MD, International Medical Education Academy, Myanmar

Additional TLM board members and other esteemed contributors to TLM’s peer review process participated as active listeners in GCP discussions as allies and are committed to supporting the GCP’s efforts going forward:

• Candace J. Chow, PhD – Assistant Professor, Department of Internal Medicine, Spencer Fox Eccles School of Medicine at the University of Utah – TLM Deputy Editor

• Heeyoung Han, PhD – Associate Professor, Department of Medical Education, Director of Faculty Affairs, Southern Illinois University School of Medicine, USA – TLM Deputy Editor

• Wendy Hu, PhD – Associate Dean in Learning and Innovation and Chair, Professor of Medical Education, Western Sydney University

As a first tangible step, GCP members ideated a paper delineating steps that publishers, editors, reviewers, and others in a position of power could take immediately to challenge oppressive structures in health professions education publishing. The result is an article that is currently under review at a peer-reviewed academic journal (other than TLM). The group’s next undertaking will be to more formally join TLM’s equity mission as a global advisory group, working hand-in-hand with the Editor in Chief (ATC) and International Editor (AA) to engage in such activities as advising on author guidance and editorial and peer review processes, peer reviewing manuscripts in their areas of expertise and passion, collaborating on position papers on topics of global Diversity, Equity, and Inclusion (DEI), and advising TLM’s global DEI initiatives. Some will join TLM’s editorial board.

The TLM GCP is situated within a larger context of global academic equity efforts by other health professions education journals and organizations.^10–13 These include initiatives by journals to (1) deepen global connections and partnerships through diversification of editorial boards and peer reviewer cadres, establishment of international advisory groups, and participation in international conferences; (2) provide scholarly development/support for international authors via workshops, consultations, internships, office hours, and direct support for English writing; (3) widen access to publication through special issues on global topics, solicitations for globally diverse author teams, and scaled article processing fees; and (4) engage in formal self-development through critical self-examination and formal DEI policies.

The GCP stands apart from other global academic equity efforts for multiple reasons. Specifically, it must be stressed that the GCP’s aim is to create something new—even though it is more difficult14—by focusing on dismantling unjust structures in health professions education publishing, rather than facilitating scholars’ participation in oppressive systems.¹⁵ What is more, GCP members exemplify resistance via action. While the organizing committee initially envisioned the GCP as a platform for global community building and professional development, the very first meeting revealed that the top-down approach they had imagined—where they would lead the group and evaluate the impact of their effort—was not aligned with members’ expectations. Despite the intentionality behind their approach to decolonizing health professions education publishing, it risked replicating the oppressive structures often imposed on marginalized groups.¹⁵ For this reason, the GCP became a highly collaborative and decentralized space early on. Although their meetings and interactions can be tense due to the nature of the conversations, the group has demonstrated a great deal of trust, passion for connection, and a tenacious commitment to challenge themselves and others to dismantle both external and internalized forms of epistemic oppression. For instance, out of a sense of true equity, the GCP has determined to publish under the moniker Global South Counterspace Author Collective (GSCAC) to challenge the hierarchical norm (i.e. ‘first author-last author’ style) that dominates in academic publishing. One final example is the GCP’s commitment to maintain the safety of their space by not allowing members of overrepresented groups in health professions education¹⁶ publishing to join.

We would like to encourage our peers, in particular those who hold a position of power as editor or peer reviewer, to think creatively of ways they might themselves become part of authentic change by empowering those who have not historically been included in the shaping of academic publishing structures. Without question, TLM is already changing in response to the perspectives and challenges we have received, not only from GCP members, but also from our authors,¹⁷ our editorial interns,¹⁴ and our increasingly diverse and equity-focused editorial board. This can be seen in our updated instructions to authors and peer review process, which have been re-imagined according to the equity mission we designed with input from these stakeholders. In addition, representation of Global South authors among our publications has dramatically increased. Although we seek still greater diversity among our editorial board, the GCP demonstrates how our equity mission has been facilitated by empowering board members with lived experience of academic inequity, regardless of where they currently live. The changes TLM has already enacted would be impossible without the tireless dedication of the organizing committee and continued engagement of GCP members themselves.

Anna T. Cianciolo
Department of Medical Education, Southern Illinois University School of Medicine, Springfield, USA[email protected]
Anabelle Andon
Medical Education, Columbia University Vagelos College of Physicians and Surgeons, USA

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