Vanstone Meredith, Grierson Lawrence
Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
McMaster FHS Program for Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada.
Med Educ. 2022 Jan;56(1):91-97. doi: 10.1111/medu.14659. Epub 2021 Sep 15.
Social power has been diversely conceptualised in many academic areas. Operating on both the micro (interactional) and macro (structural) levels, we understand power to shape behaviour and knowledge through both repression and production. Hierarchies are one organising form of power, stratifying individuals or groups based on the possession of valued social resources.
Medicine is a highly organised social context where work and learning are contingent on interaction and thereby influenced greatly by social power and hierarchy. Despite the relevance of power to education research, there are many unrealized opportunities to use this construct to expand our understanding of how physicians work and learn. Hierarchy, when considered in our field, is typically gestured to as an omnipresent feature of the clinical environment that harms low-status individuals by repressing their ability to communicate openly and exercise their agency. This may be true in many circumstances, but this conceptualization of hierarchy neglects consideration of other aspects of hierarchy that may be generative for understanding the experiences of medical learners. For example, medical learners may experience the superimposition of multiple hierarchies, some of which are fluid and some of which are calcified, some of which are productive and helpful and some of which are oppressive and harmful. Power may work 'up' and 'across' hierarchical ranks, rather than just from higher status to lower status individuals.
The conceptualizations of how social power shapes human behaviour are diverse. Often paired with hierarchy, or social arrangement, these social scientific ideas have much to offer our collective study of the ways that health professionals learn and practice. Accordingly, we posit that a consideration of the ways social power works through hierarchies to nurture or harm the growth of learners should be granted explicit consideration in the framing and conduct of medical education research.
社会权力在许多学术领域有着多样的概念化界定。它在微观（互动层面）和宏观（结构层面）都发挥作用，我们认为权力通过压制和生产来塑造行为与知识。等级制度是权力的一种组织形式，根据对有价值的社会资源的占有对个人或群体进行分层。
医学是一个高度组织化的社会环境，工作和学习都依赖于互动，因此深受社会权力和等级制度的影响。尽管权力与教育研究相关，但利用这一概念来拓展我们对医生工作和学习方式的理解，仍有许多未被发掘的机会。在我们这个领域，等级制度通常被视为临床环境中无处不在的特征，它通过压制低地位个体公开交流和发挥能动性的能力来伤害他们。在许多情况下可能确实如此，但这种对等级制度的概念化忽略了等级制度其他方面的考量，而这些方面可能有助于理解医学学习者的经历。例如，医学学习者可能会经历多种等级制度的叠加，其中一些是流动的，一些是固化的，一些是有建设性和帮助性的，而一些则是压迫性和有害的。权力可能在等级层级中“向上”和“横向”起作用，而不仅仅是从高地位个体流向低地位个体。
关于社会权力如何塑造人类行为的概念化界定多种多样。这些社会科学观念常常与等级制度或社会安排相关联，能为我们对健康专业人员学习和实践方式的集体研究提供很多启示。因此，我们认为在医学教育研究的框架构建和实施过程中，应明确考虑社会权力通过等级制度来促进或阻碍学习者成长的方式。
