Charged Topics in Medical Education: Students’ Perspectives on Power, Voices, and Faculty Engagement

Research Paradigm

This qualitative research study employed a critical constructivist approach, emphasizing that knowledge is socially constructed and shaped by power and ideology [14]. This paradigm aligns with our research question, which explores how medical students interpret and navigate charged conversations that are influenced by hierarchical and cultural power structures. The approach is also consistent with our conceptual framework of educational cultural hegemony, which examines how dominant ideologies shape what is considered normative or marginalized in educational contexts [13]. The interview questions were designed to elicit meaningful, rich, and thoughtful dialogue, followed by iterative review and discussion within the research team to develop a shared understanding of what participants said and what they left unsaid.

Educational Setting and Participant Sampling

The study was conducted in 2024 at The George Washington School of Medicine and Health Sciences (GW), a private, federally chartered four-year medical program known for its diverse student population. The research team sent recruitment emails to medical students from all four years via class list-servs. Students completed a demographic form and were purposefully selected to ensure diversity reflective of the student population.

Sample size was guided by the concept of information power, which refers to the degree to which a sample contributes pertinent and comprehensive information [15]. Given the focused study aims, the research team estimated a total of twenty interviews, with approximately 4–5 participants from each class, to ensure a comprehensive understanding of the range of experiences across GW’s medical school. After each interview, the team evaluated the quality of data obtained, the range of perspectives included and whether additional data contributed new insights to the study’s themes. Institutional Review Board approval for human subject research was obtained prior to commencement (NCR235129).

Data Collection

The research team created three scenarios based on their own teaching experiences and follow-up prompts related to the research questions (Table 1). The scenarios served to sensitize participants to discussion of charged topics in a classroom setting, including affirmative action, birth control and abortion coverage, and gun control (Supplemental Digital Appendix 1 for full interview guide). A trained research assistant (MM), not on faculty in the medical school and not known to the students, conducted all interviews virtually, with most lasting 60–90 minutes. With participant consent, interviews were recorded and transcribed using a secure online transcription service, reviewed for accuracy, and de-identified.

Data Analysis

Transcripts were uploaded to Dedoose® (version 9.2), an online platform for collaborative qualitative data analysis. We applied Braun and Clarke’s six-phase approach to reflexive thematic analysis, which involves familiarization with the data, coding, developing and reviewing themes, defining and naming them, and producing the final report [16]. Thematic analysis allowed for systematic coding while remaining flexible to incorporate both inductive insights and theoretically informed interpretations, consistent with our critical constructivist paradigm. Guided by the concept of educational cultural hegemony, the research team paid particular attention to instances where student perspectives were silenced, marginalized, or privileged within the learning environment.

Two research team members (MA and SS) independently reviewed the first three interviews conducted to generate codes. Subsequently, three research team members (MA, SS, and MM) independently coded the remaining interviews, with two members coding each one. Through iterative collaborative analysis, the research team developed and refined themes from initial codes, ensuring a rigorous and comprehensive interpretation that captured the nuanced experiences of participants.

Critical Reflexivity

Reflexivity was employed to address potential bias in data interpretation. The research team comprises individuals with diverse social identities and professional roles: faculty and clinical educators with varying experiences facilitating discussions of charged topics, and researchers with expertise in qualitative methods and social justice. Team members engaged in explicit reflexive dialogue through virtual meetings and email exchanges to surface assumptions about neutrality and authority, reflect on how their own backgrounds and political beliefs might influence interpretation, and consider how their positionality informed analytic decisions. When interpretations diverged during coding and analysis, the team examined how their varied relationships to institutional power and commitments to equity shaped their perspectives. Importantly, the team maintained awareness that this study privileges the learner’s vantage point, and reflexive practice helped ensure analyses remained grounded in students’ experiences rather than the researchers’ own facilitation practices.

Theme 1 Constrained Voices: How Hierarchy Shapes Student Voice and Expectations of Educators

Participants felt a need to discuss charged topics in educational spaces so they could prepare for conversations that might arise with patients or on public health topics. Yet, they described how power differences in educational spaces shaped what felt safe to say.

Participants brought up the need for “an opportunity to have a conversation” (P6) and highlighted the importance of discussing charged topics as part of the curriculum due to its direct relationship to patient care. However, the participants’ comfort in discussing such topics was tied to their perception of the educator’s authority and power, as well as concerns about what their peers might think of them.

The educator’s position of authority alone was enough to prevent students from speaking up, amplifying dominant narratives. “Students may not feel comfortable speaking their minds if a teacher … says that this is what they believe in, the students would need to obey that or to respect that, especially in medical settings.” (P18)

Some participants reported feeling unsafe and disheartened when they heard educators’ views that opposed their own. For example, P9 noted that “it might affect future interactions with and my perspectives on faculty, depending on what their views are.” Participants also feared potential consequences for discussing charged topics because educators were also their evaluators. “I’ll be afraid that I’d be affected in some way, whether they’re grading me or evaluating me. Maybe their viewpoint will affect how they view me.” (P1) Participants noted that the educator’s view of them was of particular importance in clinical years as the grading policies are “very subjective.” (P19) For students, the stakes are high if they do fail: “I don’t have a choice to fail here, so therefore I must keep my mouth shut. Otherwise, I face over $400,000 of debt.” (P10)

The importance of safe space and ground rules came up repeatedly as participants discussed the context for these conversations. The context was especially important in settings where hierarchy was diminished, such as in small groups. Weekly small groups, where close relationships with classmates and faculty are formed, provided such contexts, “…there are a bunch of data points that they’ve gathered about me, the person, that if I say something they don’t agree with, then also, we’ve joked and laughed and spent a hundred other sessions together.” (P13) In contrast, participants expressed hesitation in addressing charged topics in larger groups, such as clinical settings or lecture halls, where they felt less safe to speak up because of the number of people present.

Theme 2 Burdened Voices: Marginalization and Unequal Labor in Charged Discussions

Factors such as religion, gender, race, and ethnicity influenced how participants interpreted comments in the learning environment. Participants who identified as Black or from underrepresented backgrounds acknowledged that some discussions place an undue burden on them to defend and educate their peers and faculty. “Things like (affirmative action favors Black people) have been said in my small group…and my instructor kind of just glosses over and doesn’t really address it in any way; and it leaves the onus on the students to voice their concerns. …A lot of times, it’s difficult, especially if the student is a Black student who’s underrepresented in medicine, to put themself in the center of that conversation and discuss it with their peers.” (P2)

Another participant reflected on the cumulative toll of such exchanges about affirmative action: “My identity as a Black woman in academia has been literally littered with comments [that] perpetuate things like imposter syndrome, and stereotype threat….” (P16) Despite this weight, many still felt compelled to speak up, sometimes because remaining silent carried its own form of moral injury.

The repetitive nature of some charged discussions while not listening or implicitly devaluing marginalized voices and experiences contributed to participants frustration and moral distress. One participant, who grew up interpreting for her immigrant parents in medical settings, explained during one small session why children “should not be interpreters” (P8), drawing on both personal experience and research. When a peer later repeated, “We should have the child do it,” she felt her contribution had been dismissed, highlighting the burden of repeatedly having to correct assumptions.

Educators from marginalized backgrounds were often better received when discussing charged topics, as their lived experiences provided authenticity and added depth to the conversation. One participant explained, “I think that I would be more willing to hear someone’s opinion (about affirmative action) … if they are a member of a marginalized community.” (P15)

Theme 3 Finding Voice: How Students Assert Agency in Charged Discussions

Participants discussed how medical practice does not exist in a vacuum – healthcare intersects with social issues like access disparities, institutional policies related to minorities, and reproductive rights. Discussing charged topics was described as critical because avoiding such discussion could cause students to feel isolated and ultimately result in physicians who are ill-equipped to navigate the complex social realities their patients face.

Participants noted the “expectation that the faculty would address a comment, for example, pertaining to affirmative action favoring Black students” (P11) as opposed to just trying to table the discussion or saying, “Discuss it outside of class” (P2) or just “sweeping it under the rug.” (P1)

The aim of such discussions was seen to center patient care, preserving its quality and equity, rather than changing the mindset or opinions of peer learners. “I’m not here to convince John Smith in my class. I’m here to make sure his or her, their future patients are getting the best care possible, which would happen when we…. find a more truthful understanding of the world around us.” (P9) The participants noted that prioritizing dialogue about charged topics was crucial for deconstructing siloed thinking and checking biases that can impact clinical judgment, otherwise training doctors: “are going to come out of residency as biased individuals, and they’re going to provide care in a biased manner. Ultimately, biased care is subpar” (P4). The students valued diverse points of view, and learning from each other, but also understanding the context from their peers’ differing points of views and humanizing the conversations by associating “(patient)faces to these concepts.” (P8).

For many, speaking up was tied to supporting their peers or advocating for patients: “So much of being an ally is just showing up in those moments.” (P11) Participants often grounded their position in personal experience, for example around topics like gun control, “Our generation has lived through a lot of mass shootings, so I don’t think there’s any harm in saying my opinion, saying my own experiences with them, because unfortunately, we’ve had a lot.” (P8) Others expressed a sense of responsibility to stand up for patient’s right, for example in view of reproductive rights, noting that assumptions that “deny people autonomy” (P9) should not determine who receives care.

Some participants felt certain topics had a clear ethical and professional “right answer”, viewing keeping those topics as neutral as unnecessary or even frustrating. “Why is it being kept neutral? I don’t think there’s a reason to.” (P19) Another questioned the need for evidence, “I have this thing where it really sucks that people don’t believe things are true unless they see the study.” (P16)

Participants felt that being neutral as a student meant for some “[I] don’t know if I know enough about a topic to even say one way or another” (P10) while others were concerned that expressing a perspective might hurt a peer’s feelings or worse, lead to negative repercussions.

Theme 4 Guiding Voice: Student Expectations of Educator Engagement in Charged Discussions

Participants described ideal educators as those who guide student learning objectively and professionally while sharing their experiences and perspectives. They also expected educators to be knowledgeable, able to discuss relevant facts and address unexpected topics- such as affirmative action- confidently.

Students particularly valued educators sharing evidence-based knowledge grounded in guidelines and clinical experience, emphasizing practical, real-world insights and their relevance to clinical practice.“I like to usually stick to more concrete and objective facts or characteristics about a person. […] it’s more about their expertise and their educational background,” (P18) and “it’s also important to hear from, again, disproportionately emergency medicine physicians who are dealing with the wounds where those bullets go… from an expert, someone with experience’s standpoint.” (P13)

Participants expressed a curiosity, if not a clear desire, to know educators’ perspectives on the scenarios and valued it when educators openly shared their views. One reason for appreciating this openness was that it helped students learn and formulate their own opinions. “Especially this person being a mentor and someone who we respect, I would want to also hear their opinion, because [how] they’re thinking about it could impact my thinking, but also, of course, could impact my perception of them.” (P16) Another reason was that it allowed them to assess whether they could trust the educator to be non-discriminatory and not harbor racist views. Additionally, attempts by educators to remain neutral were often seen as problematic: “If they are not disclosing their opinion, and then if the faculty happens to talk on the subject later on and gives evidence for or against, then it feels as if they’re covertly trying to influence the opinion of the crowd that they’re instructing, which would dissuade me as an individual from trusting them.” (P10)

Educators’ silence was seen as a form of power as well as an opinion, acting as a form of hegemonic reinforcement: “I think it would be very telling of them to not say anything.” (P17) Or if they are not openly sharing their perspective, they are hiding something “you get this sense that the individual is hiding whatever it is that they actually feel.” (P10)

Several participants suggested a bi-directional approach where educators could facilitate discussion first, allow students to exchange viewpoints, and only then share their own, an approach described as: “Let’s have a discussion about both sides… and then… I’d be more than happy to share my thoughts.” (P4)

Implications for Practice

Faculty development in facilitation of charged discussions is crucial to prevent marginalizing students with alternate points of view and to ensure safe spaces. The students leaned towards authenticity and appreciating knowing their educator’s point of view, even if it contradicted their own. However, there is a fine line between authenticity and creating psychologically safe spaces that would require not just faculty development but also deep reflection and potentially years of experience in dealing with charged conversations, especially those that arise unplanned in the classroom. Hess and Kite propose that a facilitator’s positionality can be used as a pedagogical tool, with the caveat of explaining to students the purpose of sharing their positionality. Such sharing requires bringing opinions and identities to the foreground in some instances or choosing to withhold an opinion in others to promote a discussion in the classroom [20, 23]. Most importantly, purposefully and thoughtfully incorporating charged topics into the longitudinal small group curriculum can help in reinforcing effective spaces for such discussions. While students mainly emphasized the role of the educator in guiding charged discussions, medical educators will also need to prepare students to engage in these conversations effectively. A summary of our study findings and implications is found in Figure 1.

Figure 1

Limitations

The geographical and institutional context of our investigation—a single academic center situated on the East Coast of the US- potentially reflects predominant progressive ideological orientations that may exhibit homogeneity on certain topics. Nevertheless, the findings presented can inform other institutions’ pedagogical approaches to evaluating their specific contextual environments and engaging relevant stakeholders in deliberations regarding the integration of charged topics within curricular frameworks. Although the sensitizing scenarios employed in this inquiry are predominantly contextualized within the US sociopolitical landscape, potentially limiting international generalizability, the global phenomena of transnational population movement and increasing incidence of firearm-related mortality and morbidity across multiple geographical regions suggest that these findings may catalyze meaningful discourse beyond US territorial boundaries.