Dismantling the master’s house: new ways of knowing for equity and social justice in health professions education

Abstract

Health professions education (HPE) is built on a structural foundation of modernity based on Eurocentric epistemologies. This foundation privileges certain forms of evidence and ways of knowing and is implicated in how dominant models of HPE curricula and healthcare practice position concepts of knowledge, equity, and social justice. This invited perspectives paper frames this contemporary HPE as the “Master’s House”, utilizing a term referenced from the writings of Audre Lorde. It examines the theoretical underpinnings of the “Master’s House” through the frame of Quijano’s concept of the Colonial Matrix of Power (employing examples of coloniality, race, and sex/gender). It concludes by exploring possibilities for how these Eurocentric structures may be dismantled, with reflection and discussion on the implications and opportunities of this work in praxis.

Dismantling the master’s house: new ways of knowing for equity and social justice in health professions education

At the time of writing, statues are falling. There are protests on the streets. Calls for defunding resound as TikTok videos, Twitter unrolls, and gatherings proliferate on Facebook. There are tents occupying lands outside government buildings. There are declarations of racism in parliament buildings. There are boil water advisories. There are COVID-19 outbreaks in the dense housing camps offered to migrant laborers. There are names of sports franchises being reconsidered. There are bodies being subjected to violence. There are wellness checks that end in death. There are confrontations in parking lots. There are heated discussions on social media. There are some people telling other people to “go back to where you came from”. There are the “you’re wrongs”, “you’ve gone too far” and “angry mobs”. There are people on their knees. There are body cameras. There are commitments and statements and promises being made. There are temporary profile pictures. There are resignations, partings of ways, and new starts. There are interviews and conversations. There are “I told you so’s” and “what took you so longs” and “we’ve been saying this for years”. There are questions being asked and ideas being challenged. There are people just trying to breathe.

A perspective on perspectives

In the dominant white North American (Eurocentric) society, these are examples of what is being seen in the media, what is being messaged about, and what is being debated over dinner tables. This is what dominant organizations, regulatory bodies, and publishing houses in Health Professions Education (HPE) are sharing on social media and why there have been so many calls for change. This white North American framing is one perspective from “the Master’s House” (Lorde 2007). For some outside this perspective, that of equity-deserving groups who have long been marginalized, this seemingly ‘woke’ perspective has been described as possibly self-serving, perfunctory, concerningly rhetorical, and hopelessly late (Gutierrez 2020; Spaulding 2020; Yancy 2020).

Readers of this journal may recognize their own perspective reflected somewhere in the above text; perhaps you are a curriculum director of an HPE program, perhaps you are a theorist, a dean, a trainee, a teacher, a clinician or a community member. As journal contributors, ‘we’, the authorship team displayed here also encompass multiple perspectives: ‘we’ are hospital leaders, education professors, university faculty, staff and students, clinicians and theorists. But ‘we’ is not the same as ‘I’ and ‘our’ perspectives are diverse (and purposefully so). ‘We’ represent perspectives of both dominant and equity-deserving groups. ‘We’ are named as Black, Brown, and White. ‘We’ are named as Canadian, Muslim, Scottish, Nigerian, American, Onondaga, Pakistani, Jewish, and South African. ‘We’ live in Canada, the United States, and South Africa. ‘We’ are bounded as married, single, and attracted to members of the same-sex and opposite sex. ‘We’ write, follow, and administer policy. ‘We’ create, operationalize, theorize, and experience curricula. ‘We’ write from within the Master’s House and are attempting to dismantle it. ‘We’ were invited to write this paper by the journal because of our expertise and experience: a senior author in the field who is a Deputy Editor at this journal, her graduate student, and experts in theory and praxis who we invited to join as co-authors. As ‘we’ come together to write as a team, and as you the reader encounters this piece, all of ‘our’ collective individual perspectives, identities, and roles are in tension. Statements that ‘we’ write here and appear to be declarative are debated. Statements that ‘we’ claim are true might only be true for one of us and ‘we’ cannot make claims to truth beyond ‘our’ collective experience. Claims ‘we’ make in ‘our’ writing or actions ‘we’ seek may be both radical and militant and also cautious and careful. The ideas emerging from this paper stem from multiple ontological and epistemological traditions, so as ‘we’ proceed in our writing, and you proceed in your reading, we invite you to consider why we might write this and from which standpoints we write. What shifting privileges do we enact? Are we writing from within the Master’s House, or from outside of it? Will our writing collectively, through identity, form and performance, loosen the mortar of the house, are we still adding bricks reminiscent of an all too familiar pattern, or are we doing both at the same time? We invite you to question these multiple perspectives as a reader, and at the same time, question your own.

The master’s house

Grosfoguel argues that the structure of knowledge upon which the Western University (and, we would argue, by extension HPE) is built on a canon of thought “based on the knowledge produced by a few men from five countries in Western Europe (Italy, France, England, Germany and the USA)” (Grosfoguel 2013, p. 74) and on a structural foundation evolved from late 15th century conquests of territories and religious genocides (Grosfoguel 2013). Rather than a Christian God as the foundation of knowledge, Descartes’s philosophy of “I” (“I think, therefore I am”) and the Enlightenment thinkers that followed him moved Western philosophy away from having one fundamental category of things and towards the separation of the body and the mind. This dualism then raises questions about consciousness, intentionality, and the self (Robinson 2020). Constructing man as having control over the mind, beyond a Christian God, afforded the Western man who held power epistemic privilege: power over how knowledge is structured (Robinson 2020). This privilege has been used in conquests over religion and territories, and continues through colonialism. We would argue that medicine and medical education rely on this privilege.

The dominant discourses at work in most Western universities and medical education have positioned knowledge production as based on the perspective of a knowing subject or zero-point epistemology (Castro-Gómez 2001; de Sousa Santos 2008; Naidu 2020). The zero point is a reference to the avowedly objective stance of how white Western science produced knowledge: the ‘truth’ scientists seek is both nowhere and everywhere; we would claim it just ‘is’, as a zero point. It is an “imaginary position of those who claim neutral objectivity for themselves—an unseen position that presumes to see all” (Soldatenko 2015, p. 140). Within this frame, science is constructed as a search for a neutral objective truth where “it is possible to achieve objectively valid knowledge about the physical and social world by merely using the appropriate method” (Castro-Gómez 2001, p. 149). This construction is heavily rooted in the global material and social interests of (white) “men from five countries (France, England, Germany, Italy and the USA) who are the ones monopolizing the privilege and authority of canons of knowledge production in the Westernized university” (Grosfoguel 2013, p. 87; Cupples and Grosfoguel 2018).

Rooted in these global histories of power this zero-point epistemology result in forms of epistemic injustice and epistemic violence (Fricker 2007; Ndofirepi and Gwaravanda 2018; Soldatenko 2015; Spivak 1988). Fricker (2017) describes two types of epistemic injustice: testimonial injustice and hermeneutic injustice. Testimonial injustice occurs when someone’s words are misjudged and considered to be less worthy than another’s due to prejudice. An example in a healthcare setting would be a health professional who ignores a patient’s medical complaints due to prejudice or racism (Hoffman et al. 2016; Lowrie and Malone 2020). Hermeneutic injustice occurs when two people do not sufficiently share the same knowledge base such that a shared understanding of a situation cannot be reached. An example in healthcare may be when those with privilege cannot understand why those without the same privilege are unable to access the same resource (Florko 2020). The zero-point perspective, combined with these forms of epistemic injustice, further manifest in contemporary healthcare practice as a privileging of methods, practices, forms of evidence, and ways of knowing which have become “a common, possibly pervasive, feature of healthcare” (Carel and Kidd 2014, p. 538).

HPE programs and the evidence that we use to build them are so embedded within this perspective that how the health system has been constructed appears to be ‘natural’. We posit that it is through this very system that we have been conditioned not to question why we think we know what we know, or why we think some ideas are ‘core’ to curricula while others are not, or why we think we can improve upon anything built within this Master’s House of HPE. Professional schools in Europe and North America have been built from this zero-point epistemology and have gone on to spread this globally. We argue that the planting and proliferation of HPE as founded on the pillars of sexism, racism, patriarchy, authority, buffeted by capitalism, and grounded in the dominance of the zero-point epistemology of white ‘men from five countries’ is evident in history. In 1852, Newman positions the university as a place for the cultivation and contemplation of the truth for the formation of gentlemen (Newman and Turner 1996). Writing in the early 1900s, Flexner positions the ideal medical program as one devoted to the pursuit of knowledge and facts (Flexner 1968, 1972) and a profession as “an order, a caste [with] a code of honour” (1968, p. 30). In the 1960s, Kerr (1963) positions the university as a “producer, wholesaler, and retailer of knowledge” (p. 114). Later still, Slaughter and Rhoades (2004) position the university as an academic capitalist knowledge/learning regime. Saks (2016) notes that the power and privilege of the professions is based on the state-sanctioned control over knowledge.

From within HPE, the rules of the Master’s House authorize what knowledges can be circulated and spoken of as truths and in turn, what role a practicing health professional serves in the community. In these educational programs there are curricula, standards, learning objectives, expected outcomes, and standardized tests set on the dominant ways of knowing. Those who graduate from these schools, members of self-regulated health professions, are seen as guardians and reproducers of boundaries and status through codified systems of thought (Freidson 2001). However, the “politics of domination are often reproduced in the educational setting” (hooks 2014, p. 39). Physicians, for example, have been viewed as contributors to imperialist struggles (Aidoo 1987; Fanon 1994). This epistemic violence endures and concerns continue to be raised about colonization through medical education (Muzzin and Martimianakis 2016; Naidu and Kumagai 2016; Whitehead 2016) and medical practice (Sharma 2018). In the pursuit of knowledge production, the House of HPE continues to place value on the ideologies of the Enlightenment—on positivism, universalism, and rationalism—rather than other potential goals of education, such as liberation (Freire 2000). In so doing, we argue, HPE creates, authorizes, and reproduces domination, privilege, and status and education is seen as an individual achievement and not a means for improving circumstances within society. Based on these dominant epistemologies, we argue that many HPE educators focus attention in demonstrating an individual’s professional responsibility in practice, and focus less on the social responsibility of that practice.

Equity and social justice are themselves positioned somewhat uncomfortably within HPE curricula because of their origins. This may be surprising as the idea of equity and social justice is often considered as a stance against the rationalist positioning of the Enlightenment. While at first glance the concepts of equity and social justice may appear to be in opposition to the rational, universal, positivist biomedical model, we and others argue that the modern (settler) North American and European constructions of equity and social justice are tied to the same beginnings of the zero-point epistemology: conquest, the Enlightenment, and subsequent coloniality. It is a colonial model of power that is sustained within the Master’s House. Even “modernity was also colonial from its point of departure” (Quijano 2000, p. 549). One cannot discuss equity and social justice without first having built and defined inequity and injustice. One cannot discuss anti-racism without the existence of the construct of race. If the contemporary HPE that is the Master’s House is structurally unsound (and we argue here that this is so), then no amount of implicit bias training or well-crafted diversity statements can erase the centuries of epistemic violence. Van Milders explains the problem with diversity statements in Western academia thus: “the contemporary university has managed to appropriate identity politics and the unsubstantiated celebration of diversity in order to obscure issues of raced, gendered, and classed difference and thereby leaves the hegemonic invisibility of whiteness untouched (van Milders in Cupples and Grosfoguel 2018, p. 47). His explanation emphasizes that diversity statements leave power structures untouched: if the university or professional structures that act as gatekeepers are the same institutions that define the concepts of equity and social justice, or that implement supposed solutions to these issues, then they may be doing nothing more than erasing differences (Cupples and Grosfoguel 2018) and perpetuating coloniality.

Intertwined with the building of post-Enlightenment nation-state economics, politics, and law, science was deployed to separate people through the construction of race. Science, and our ideas of who people are or where they ‘come from’ form part of a world-system (Castro-Gómez 2001). To build an economy and gain access to resources in the world-system, one nation state colonized another. Colonizers constructed race, the notion of the Orient (Said 1979), the North/South binary, and other such dividing practices. The understanding of what the dominant discourse calls ‘modern culture’, including notions of equity, antiracism, and social justice, all sit within this frame which is held up by the constructed universalism of zero-point epistemology. The distribution and exploitation of labour stemming from coloniality and science-based constructions of identities and social value brought about forms of labour control that were differentiated by race; thus “a new technology of domination/exploitation, in this case race/labor, was articulated in such a way that the two elements appeared naturally associated” (Quijano 2000, p. 537). One can draw a direct line between this historical distribution of labour and the ongoing distribution of the labour of marginalized groups in academia and medicine (Association of American Medical Colleges 2020; Henry et al. 2017; Hodges 2020; Nestel 2004). We argue that science, and the professions that emerged from it, continue to dominate, control, and divide people.

Health professions education can no longer sustain the continuation of our current models rooted in coloniality and epistemic violence. In order to reframe equity and social justice, we suggest that we need a new vision of HPE; one derived from epistemological and ontological positions that move beyond the zero point to embrace partial perspectives, situated knowledges, and the borderlands of identity and position (Anzaldúa 1999; Haraway 1988). Dismantling the Master’s House will give “way to new ways of global structuring” (Castro-Gómez 2001, p. 152) and new pedagogies of possibility (Motta 2013).

We began this piece describing moments in time, bearing witness to these moments, and participating ourselves in a multitude of different ways to address epistemic injustices. Perhaps the Canadian poet Dionne Brand (2020) describes this moment the best. A moment when “everything is up in the air, all narratives for the moment have been blown open—the statues are falling—all the metrics are off, if only briefly.”

Dismantling the master’s house

Dismantling the Master’s House calls for an interrogation of how difference is constructed within HPE, who has been advantaged by these conceptualizations, how these have manifested in education and practice, and how these patterns continue to perpetuate inequities in HPE. What are the alternatives to the long dominant zero-point epistemologies? We will employ three interconnected examples as illustrations: coloniality, the constructs of gender and sexuality, and the construct of race. However, these are just three possible partial perspectives; we could have also, for example, explored health status, ability, religious beliefs, Indigeneity, or socio-economic status. We have selected coloniality, gender and sexuality, and race for a number of reasons. First, they emerge out of zero-point epistemologies stemming from conquest and colonization; second, the global Colonial Matrix of Power is constructed on the foundation of racism and is held up by gender and sexuality as a sphere of power; third, these are areas of particular interest to us collectively and individually as members of health professions education; and fourth, there is hope that through their interrogation, we can imagine new possibilities.

Coloniality

The concept of coloniality was developed as a response to both colonialism and postcolonialism. Colonialism refers to the practice of domination where one group of people subjugate another (Kohn and Reddy 2017). While colonialism has been ongoing in world history, for the purposes of this paper we refer primarily to the current period of colonization by European powers that started in the 16th century and encompassed people and territories in Asia, Africa, Australia and New Zealand, and the Americas. Colonialism is often only thought of as the act of imperialist powers conquering new territories and plundering their resources. However, at the same time, imperialist powers were exporting the ideals of the Enlightenment, including how economies and societies should function. Sophisticated traditional education practices were disrupted or eradicated. Through the hegemonic disruption of generations of knowledge, colonialism led to “cultural genocide, linguicide and epistemicide”—the killing of culture, language and Knowledge Systems (Hall and Tandon 2017). It is why, we argue, students in most Canadian schools are educated in English and French but not in Inuktitut or Ojibway; why the ‘traditional’ literary canon contains Shakespeare but not Soyinka, why what we call ‘narrative’ is primarily written and not oral, and why our understanding of how our bodies function is biological, not spiritual. These knowledges stem from colonial epistemologies and much of what the modern university now positions as legitimate, ‘real’ and ‘true’ is positioned from this colonial dominant norm (Hall and Tandon 2017).

Postcolonialism emerged as a response to approximately 400 years of Eurocentric colonization. It is defined as:

studied engagement with the experience of colonialism and its past and present effects, both at the local level of ex-colonial societies, as well as at the level of more general global developments thought to be the after-effects of empire. Postcolonialism often involves the discussion of experiences of various kinds such as those of slavery, migration, suppression, and resistance, difference, race, gender, place…. (Schwarz and Ray 2008, p. 93)

Postcolonialism argues that the ‘self’ has been socially constructed; the dominant powers of imperialism generating the binaries of us versus them, white versus black, and West versus East (Said 1979). Socially constructed identities are built up in layers, conditioned by dominant knowledge practices to always see oneself in relation to an ‘other’ (Bhabha 2012). Postcolonialism is, in part, not only a political and economic response but an epistemological one, challenging the dominant positivist norm developed through the Enlightenment and colonization that everything can be singularly defined. Postcolonialism is not tightly bound and can be viewed as “a field, or a perspective, or a political commitment” (Loomba 2015, p. 4). Defining “postcolonialism” is describing instead a resistance to knowledge practices that attempt to whittle it down to a single rationalized and reductionist definition.

Many scholars resist the idea of postcolonialism and instead frame their work through the concept of coloniality. Coloniality positions itself as a tangible form of decolonizing knowledges—moving away from the reliance on postmodernist Eurocentric thinkers (such as Foucault, Gramsci, and Derrida) to knowledge imbued with marginalized epistemological philosophies, traditions, and systems of thought (Grosfoguel 2011). For example, Gloria Anzaldúza (1999) calls for a new inclusive, mixed consciousness of the borderlands to unentangle the self from subjugation. Frantz Fanon (1963, 2008) and Steve Biko (2015) invite one to consider that revolution, force, or violence may be needed to emancipate society from dialectic constructions of the self. What these have in common is their celebration of a knowledge practice that recognizes difference. Using frames of coloniality or decolonization move us thoughtfully away from forms of knowledge that erase differences, conceal subject positions, and makes subjects “think epistemically like the ones on the dominant positions” (Grosfoguel 2011, p. 5).

One tool that helps demonstrate how a Western “modern” epistemology advantages some groups but not others is the Colonial Matrix of Power. This matrix (Mignolo 2007; Quijano 2000) centres knowledge, racism, patriarchy and capital as the basis of modern global power developed through colonialism. This modern global system, as Mignolo and Quijano have argued, imposed spheres of power (subjectivity, gender and sexuality, authority, and the exploitation of land and labour) as instruments of domination. These instruments are interdependent, operating in relation to one another, and serve to uphold and reproduce the modern construction of global power (Quijano 2000). Theorists argue that the Colonial Matrix of Power is “the very foundational structure of Western civilization” (Mignolo 2011, p. 16) and is “the logic that generates, reproduces, modifies, and maintains interconnected hierarchies” (Mignolo 2011, p. 17). (Fig. 1)

Fig. 1.

The colonial matrix of power (Quijano 2000) as described by Mignolo (2007)

Structural racism

A paper in the New England Journal of Medicine describes how a Black man killed in Minneapolis through the disproportionate use of lethal force by the police sparked calls for the medical profession in the United States to confront structural racism. It explains that medical professionals have a responsibility to dismantle structural racism and can begin doing so by taking specific actions: learning about historical racist roots which lead to health disparities; challenging implicit biases; defining and naming racism when it is seen, and ‘centering at the margins’—shifting away from the dominant group’s perspective to that of marginalized groups. One might imagine this paper came out in 2020 following the death of George Floyd, but it was actually written in 2016 about a man named Philando Castile who also died at the hands of the police (Hardeman et al. 2016). Hardeman calls structural racism “the common denominator of the violence that is cutting lives short in the United States” (p. 2113). She calls for both courage and change, but has much changed since?

Racism is at the centre of the structure of the Colonial Matrix of Power. While it was colonialism that classified the world’s people by the idea of race, it is racism that has endured longer than the colonial structure from whence it came (Quijano 2000). Through colonialism, categorizing or identifying an individual by geographic origin gave way to categorizing individuals based on observable characteristics (or phenotypes) which then gave way to categorizing individuals by the newly-created category of race (Quijano 2000). Racism legitimized the spread of empire and colonial economies. The conquered were constructed as racially inferior to the colonizer.

Through the Eurocentric lenses of Darwin, Smith, Saint-Simon, Compte, Newman, and Mill (and many others), European society equated progress and development with individualism, utility, education, and order and these conditions could only be realized in societies “not bound by ‘custom’ and in which tolerance and rational discussion were permitted” (Cowen and Shenton 1996, p. 41) (needless to say, only someone else’s cultural norm would be derided as ‘custom’). Colonialism and racism fit right in and as imperialist and economic expansion grew, these and similar zero-point ideas created and wove their way up and through the systems of education, health, government, and their structures and institutions.

What is racism then, and what is structural or institutional racism? It is worth quoting Camara Jones (2002) here at length. She writes:

Racism is a system of structuring opportunity and assigning value based on phenotype (“race”), that: unfairly disadvantages some individuals and communities; unfairly advantages other individuals and communities; [and] undermines realization of the full potential of the whole society through the waste of human resources. (p. 10)

Jones then goes on to define institutionalized racism as:

the structures, policies, or norms resulting in differential access to the goods, services, and opportunities of society by “race.” Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage. It is structural, having been codified in our institutions of custom, practice, and law so there need not be an identifiable perpetrator … [and it] manifests itself both in material conditions and in access to power. (p. 10)

As Quijano has argued racism and colonialism are inextricably linked, such that the global expansion of zero-point epistemology which has been centred around and focused on economic and imperial growth has resulted in generations of labour supported by racism and the structures that support it, including underpaid labour, indentured labour, and slavery.

Frantz Fanon writes to those who have been oppressed by these structures in his works Black Skin, White Masks (1994) and The Wretched of the Earth (1963). Fanon was born in Martinique, qualified as a psychiatrist in Lyon and went on to practice in Algeria (Khalfa 2015). Through his work on the wards in Algeria as a racialized physician attending to both European and Algerian patients, he identified forms of psychiatric illness as culturally determined. Fanon critiques the Colonial Matrix of Power, with the recognition that this matrix instills itself both in the thoughts and minds of the oppressor and also the oppressed. Fanon writes that a man’s life under these forms of oppression is conceived as nothing other than “the form of a battle against exploitation, misery, and hunger” (2008, p. 174) and calls for violence as the only method by which this oppression can be lifted. He writes: “colonialism is not a thinking machine, nor a body endowed with the reasoning faculties. It is violence in its natural state, and it will only yield when confronted with greater violence” (1963, p. 61). Throughout his work Fanon carefully describes how colonialism pervades the colonialized mind; how oppressive discourses become normalized, and how inequality is racialized. Although he was writing before this term was created, Fanon is describing the Colonial Matrix of Power.

The structural racism that Fanon describes in the 1960s, and Jones describes in the 2000s, continues to pervade society, including HPE and practice. Science continues to be predatory against racialized people. Ruha Benjamin writes about how stem cell research (2013) and technological design (Benjamin 2019a, b) are discriminatory against Black people. Linda Tuhiwai Smith (2008) details how structures, such as academic research, can be sites of contestation for Indigenous Peoples, with research within zero-point epistemology as something that needs to be resisted. Some primary care physicians in the United States who outwardly demonstrate egalitarian attitudes have been shown to have significant implicit biases against Black and Latino populations (Hostetter and Klein 2018). Audre Lorde (2007) refers to the structure of an academic conference as “the tools of a racist patriarchy” (p. 110) where racialized and marginalized people may only be invited to present as tokens. Patricia Hill Collins (1986) and bell hooks (2014) speak of the importance of listening to voices from outside the authoritative diction of hierarchical forms of academic dissemination (we would include this paper here too, written for a scholarly journal). hooks suggests further that academia move away from “pedagogical practices that … reinscribe systems of domination (such as racism and sexism)” (2014, p. 10).

These are just some examples used to illustrate how structural racism has built and takes its place within education and healthcare. Our structures, the privileges many of us hold, and the advantages we seek, are because the structures are built on a foundation of racism. Four years after the murder of Philando Castile in Minneapolis, we still write the same stories.

Gender and sexuality

Coloniality also imposed structures of gender upon the people it marginalized. Oyěwùmí (1997) explains how the British colonization of northwest Africa resulted in both the construction of the concept of “woman” in Yorùbá society and then their subsequent subordination in society (see also Lugones (2016)). Another example to illustrate the imposition of colonial ideas about sex and gender is the term ‘two-spirited’. Within the context of Indigenous communities in North America, the term ‘two-spirited’ referred to a multiple gender position embedded within Indigenous cultures, an individual who identifies as more than one gender orientation—not just male and not just female (gender orientation meaning the roles that one aligns with rather than the individuals to whom one is sexually attracted). However, the history of colonialism, of religious dogma, cultural eradication, the brutality of residential schooling, and subsequent intergenerational trauma led to a disruption of teachings within Indigenous communities about the meaning of ‘two spirited” (Cameron 2005). Even that was being erased by the Colonial Matrix of Power, but through significant resistance efforts and activism the two-spirited identity is being reclaimed by some within Indigenous communities (Depelteau and Giroux 2015). Further, coloniality created the category of ‘homosexuality’ (Mignolo 2011), eradicating the epistemic beliefs of multiple cultures that had not previously categorized its people in these ways.

In other words, there are conceptions of sex and gender that may appear to have been ‘newly realized’ within the dominant society but had already existed and had then been marginalized in the colonized societies that had not been afforded the same power. We argue here that such realizations about sex and gender were early indications of a questioning of the dominant zero-point epistemology from within the white European academy. The 1949 publication of Simone De Beauvoir’s book The Second Sex (2010) and Judith Butler’s works (1987, 1990, 2004) reconstruct gender not as the fixed immutable identity relied upon through coloniality, but as a “cultural interpretation” (1987, p. 36). While sex may be on a biological spectrum, gender is socially constructed; it is something we learn how to do through our relations with others.

The Colonial Matrix of Power constructs race, sex and gender as separate dividing practices, creating hierarchies where race and sex and gender became interconnected through power, such that white men had power over white women, and white women had power over Black men (Mignolo 2011). Confronting the colonial matrix thus requires a unified approach that names historical differences while working together for social justice. Audre Lorde, bell hooks and Patricia Hill Collins all speak of the importance of marginalized voices resisting the dominant racist and patriarchal society. It is here where one can more easily identify the intersectionality (Crenshaw 1989) of both race and gender. Lorde (2007) suggests that the survival of marginalized people depends on their ability to take their differences, such as gender, race, age or socioeconomic status, and make them strengths, urging readers to make the personal political, and advocate for social change. hooks further advocates for voice and change, writing “[t]rue speaking is not solely an expression of creative power; it is an act of resistance, a political gesture that challenges politics of domination that would render us nameless and voiceless” (2015, p. 8). Even though you may have a voice, or position, or title, there is still no guarantee that people will listen. Hill Collins (1986) calls for change, arguing for an Afrocentric feministic epistemology where externally-derived images are replaced by “authentic Black female images” (p. 517) to produce positive change in the self-definition and self-valuation of Black women by Black women.

Coloniality and authorship

We started this story of dismantling the Master’s House in HPE with a description of who ‘we’ are as a collective of authors, alluding to the idea that our multiple intersecting, imposed, and claimed identities should alert the reader to read our perspective with caution and scepticism and to attempt to interrogate their own positions, perspectives, and privileges in the reading. We are under no illusion that either you, dear reader, or we as authors will attain a perfected reflexive positioning. Whose voice is speaking at any point in this piece, from what vantage point, and what position? The authorship order might offer some clues over whose voices are represented and who might have the power to determine how these voices are represented. Whose voice is speaking right now, is it the voice of the first author? The voice of the senior author? Certainly, all the voices that are claimed as ‘we’ cannot be represented equally, and some might argue that some of these voices are not represented at all.

Academic convention might place the first author as a voice of privilege in the academic space, having the latitude to craft this paper and potentially shape how the content is received in HPE. In this case the first author can also lay claim to privileges, having written about these ideas during the process of her doctoral work she was invited to work on this paper originally commissioned to her doctoral supervisor, the last author. The last author, by the positioning of her name on the authorship list and having been commissioned, equally lays claim to the privileges of a legitimized and approved legitimizing voice in a powerful, well-resourced North American space. Both voices are centred from within the Colonial Matrix of Power. The first author position on a published paper is itself a valuable currency within the structure of academia. It connotes responsibility and recognition. It is often, as is the case here, a helpful position to take for a doctoral candidate disseminating ideas that they intend to employ in their research. It is a helpful position to have on one’s CV when applying for grants, positions, or promotions.

Other authors too have privileges, less obvious perhaps, but privileges that are leveraged nevertheless. Voices that have been marginalized may now write about race or gender or coloniality with less personal restraint, vigilance, or fear of judgement in one sense than white men or white women could. Some authors here perceive this privilege and leverage that here. There is an increasing expectation that voices that call out racist practices in this space will not be silenced. At the same time, authors who are from or have ancestral origins in colonized territories or who are descendants of colonized peoples can also speak and write with an accepted legitimacy about colonization and its effects. This position may afford authenticity to the collective author voice. Still others have the privilege of working as health professionals in the spaces where we can witness firsthand, reveal, and eventually dismantle traditional HPE ways of knowing and the resulting inequities and social injustices. This goes even further. There are some of us (this first author included) who has never and will never step into a clinic and act as a healthcare provider. Our orientations lean more towards theory rather than praxis. And while some also have a theoretical approach, their orientations in this work in particular will lean more towards praxis than theory.

It may seem strange to direct attention away from what might appear as the body of the text to the reflections and positions of its authors, but as we are writing about the coloniality of power, this is certainly one way to demonstrate how this is enacted. Knowledge, race, and capital are at the centre of the matrix. And at the beginning of our authorship list is a white, female, Scottish-Canadian PhD candidate who holds a full-time job as an administrator at a university and admittedly part of the problem being described here. Is it possible to also be part of the solution? Can the very people who have benefitted and uphold the Master’s House within HPE be expected to dismantle their ‘home’? Is it solely the role of those who have been marginalized to dismantle the structures of their marginalization? Right now, we do not have answers, only questions. As individuals and collectively as authors we are entangled in and must tangle with these ideas. How do we recognize and leverage privilege reflexively and respectfully? It is unlikely that the work must only fall in one direction. This work is not being compensated, is it fair to ask (as our institutions do time and time again) for the oppressed to take on uncompensated work to educate their oppressors? We think it unfair. Instead in this paper perhaps some of us start to pay a ‘majority tax’ (Mensah 2020), bringing together a group of experts who hold different roles in education and health institutions; listening to both confirming and dissenting voices with humility, leveraging privilege to advance the ideas of those who have less privilege, being honest and open and reflexive in our thinking and with each other, and positioning an argument together that might help to dismantle the Master’s House. Perhaps this is still insufficient.

We have primarily been focusing on the theoretical side thus far in these arguments. While the structure of HPE needs both theory and praxis, we also need both theory and praxis to dismantle the Master’s House. And so, we move now from theory to lived experience, intentionally away from the voice and positionality of the first author and the other theorists among us. Perhaps we will start toppling some statues of our own.

From theory to praxis: coloniality, gender and sexuality, and racism

In the examples below, some drawn directly from lived experience, we begin to show how the Colonial Matrix of Power is enacted within HPE. Together with each example, we also begin to illustrate ways in which the Colonial Matrix of Power can be resisted. We begin to show how to dismantle the Master’s House.

Students in HPE programs are often victims of inequities perpetuated within their learning environments. Several studies have shown that mistreatment of students is so commonplace within these programs that it is almost regarded as a rite of passage into the profession (Markman et al. 2019). Take for example, a white patient who acknowledges the white students in the room as medical students while dismissing the Black student as a nurse, or the student who is dismissed by a staff surgeon from an internship interview because her last name sounded “too Arabic”. These students hesitate to report such microaggressions for many reasons, some of which include fear of reprisal, perception that mistreatment is part of medical culture, or difficulty reporting more subtle forms of mistreatment (Chung et al. 2018). Indigenous students have similarly been shown to be disadvantaged in science, technology and health degrees where they encounter epistemic imperialism. In these programs, Indigenous Ways of Knowing are delegitimatized, marginalized, silenced, and challenged within curricula (Cech et al. 2017). Faculty members also experience racism, inequities and microaggressions, much of it “subtle and nuanced, yet pernicious” (Joseph 2020). This manifestation of coloniality leaves some faculty members fearful of speaking their truth, reluctant to speak up for fear of being misinterpreted, concerned of being labelled as problematic or used as tokens. These oppressive environments have caused some academic physicians to make the difficult decision to leave academic medicine, creating new spaces instead where they can speak truth to power (Blackstock 2020).

Those who research, teach, build, administer, and lead HPE programs need to re-centre their teachings of inequity and social justice on non-dominant epistemologies—such as constructivism and epistemic pluralism which counteract the neutral objectivity of the existing dominant ideologies. Perhaps the dismantling of the power dynamic within HPE is a good place to begin. If students’ experiences and/or knowledges of inequity are considered necessary and deemed valuable, then some of this knowledge can be incorporated into training on inequity and social justice by faculty who are willing to listen and learn. Likewise, for those who pursue, mentor or publish educational research, singular perspectives centred around dominant ideologies should be questioned and made visible. Those of us who are early on in our research careers could be guided in reflexivity and guided in how and where to question our long-held assumptions. Those of us who participate as peer reviewers could likewise ask to reflect on not only the author’s assumptions, but also our own. A shift from zero-point epistemology has the potential to create HPE that is centered on equity, diversity, and inclusion, and could cultivate a culture in which students, faculty and staff, especially those who are minoritized, don’t have to take it upon themselves to fight inequity or succumb to its inevitable reality as part of the learning environment. In teaching, we suggest that some of it could be as simple as thinking to include examples of dermatological conditions on non-white skin (Rimmer 2020) or no longer teaching about clinical interventions or treatments that differentiate patients using biological definitions of race (Witzig 1996).

Much of the praxis-oriented work that continues being performed in medicine centres white women, for example, calling for increases in the promotion of women to positions of leadership. But this centring on white women works to silence, homogenize, and negate the experiences of people who identify as Black, Indigenous, or people of colour (BIPOC) who not only carry the weight of the everyday stress of the job of being a clinician, but also carry the burden of multiple forms of structural racism and implicit biases that further oppress them (Cyrus 2017; Moreton-Robinson 2000). To begin to dismantle the structures that negate difference and create forms of oppression due to multiple axes of subordination we can employ an intersectional approach to change.

Intersectional perspectives (Collins 2015; Crenshaw 1989, 1991) recognize that there are multiple forms of oppression that are cumulative. For example, a Canadian-born international medical graduate (C-IMG) (someone who typically was born and grew up in Canada but who went to another country to complete medical school) will experience a clinical training program differently compared to an Immigrant international medical graduate (I-IMG) (someone who typically was born, grew up, and completed medical training outside Canada). Whereas IMGs need to adjust to life in Canada and learn the Canadian health system, a C-IMG is already aware of many of the social ‘norms’ expected of them in Canada. In a study by Najeeb et al. (2019), both C-IMGs and I-IMGs experience a form of bias and discrimination from having completed medical school outside Canada but racialized I-IMGs experienced a heightened form. Intersectionality provides a means of understanding the complex power relations that dominate medicine with the objective of alleviating social injustices in how medicine is learned, practiced, and delivered. In order to dismantle the hegemonic practices that support the Master’s House, we suggest the use of a range of pedagogies, such as those taken from Freire’s Pedagogy of the Oppressed (2000) or hooks’ Teaching to Transgress (2014), which employ critical reflection and reflexivity to better understand how one’s own identity and practices contribute to the solidification and exportation of normative discourses in HPE (Naidu and Kumagai 2016; Ng et al. 2019).

We argue here that critical reflection and reflexivity within an intersectional frame have the potential to disrupt models of health professions education and practice that have long been upheld as proverbial ‘gold standards’. Rather than institutional policies and practices or research practices erasing differences by being gender-blind or colour-blind, intersectionality and the introduction of intersectional (Eckstrand et al. 2016), previously marginalized, and community-oriented, epistemologies (Battiste 2013; Brayboy 2005; Collins 2002; Dei 2000; Gordon 1990; Naidu 2020; Rasmus et al. 2020; Smith 1999) would better enable us to embrace difference, do the difficult work of tangling with the messiness of difference, and move us forward through learning from the discomfort these entanglements produce.

Institutions themselves can drive and support this work. This might include continuing professional development for health professionals and mentors in the form of longitudinal and deep antiracist (or antisexist) training, creating space and offering structural supports (including time and salary) to aid in the hypervisible and sometimes isolating work of restitution, holding people who cause harm to account (Richardson 2020c), offering funding targeted towards underrepresented groups where systemic biases within peer review processes have often led to disadvantage (Doll and Thomas 2020), or taking into consideration during hiring, promotion, or awards processes how intersectionality doubly affects racialized faculty (and racialized women in particular) who tend to receive lower teaching evaluations than their white counterparts (Chávez and Mitchell 2020; Mohamed and Beagan 2019; Ross and Edwards 2016; Silverberg and Ruzycki 2020). Commitment to real structural change can neither be tokenistic nor temporary, it cannot appear as a strategic goal and then disappear soon after.

Conclusion

Within this paper, we have described the Master’s House, its Eurocentric origins, its dependence on zero point epistemology, and how many current understandings and practices of health professions education and social justice are embedded within this House. We utilized Quijano’s Colonial Matrix of Power (2000) to illustrate and interrogate how coloniality, sex and gender and race has been constructed within the house, giving examples of epistemic injustices along the way. We wrote quite at length in two sections of the narrative about our own perspectives as individuals and as a team of authors and provided some reflections on authorship within the Colonial Matrix of Power. In the latter section, we moved away from theory into praxis, exploring coloniality, gender and sexuality, and racism in the context of the learning environment and practice.

We have argued for the dismantling of the Master’s House. It would mean the dismantling of the house in which many of us work and learn, and from where we draw our incomes. We are not suggesting this will be easy, or comfortable, but it is needed. There are many steps we can take as individuals, as committees, and as institutions and we encourage you to seek out many perspectives and voices as you seek to engage with this work. For the audience of this journal, we suggest a few additional steps. As individuals we could pay attention to how we position our work, being mindful of not assuming our audience is similarly positioned. We can be more explicit about these perspectives as we write or speak, sharing more of ourselves, our identities, and the positions from which we speak. We can establish meaningful collaborations with less focus on retaining power or voice or hierarchy and more focus on building meaningful partnerships with people from epistemic perspectives not our own (Richardson 2020a). When structuring a reading list for a course, we can look outside the traditional canon so as to not reproduce the belief that all knowledge is white and Western. As a student in HPE, and as a sometimes named ‘consumer’ of education, one can seek out programs and courses that privilege multiple forms of knowledge. As a student or practitioner of theory we can demand of ourselves and others a careful consideration of a chosen theoretical framework, knowing that the theories we apply to our research are often developed through processes of epistemic injustice or violence. We can “disrupt with kindness” (Richardson 2020b) knowing that this is difficult work, and we are all on different stages of this journey. Some of us may need to find allies, some of us may need to act as allies, and some of us may need both.

As committees, whether we are building curriculum, admitting learners, hiring staff and faculty or creating policy, we can suggest practices or readings from non-zero-point epistemologies, using language and perspectives that recognize the Colonial Matrix of Power and seek to dismantle it, and we can center and empower the people who are positioned on the margins. As we develop our systems, we can take into account intersectionality, realizing that some individuals are doubly or triply affected by the choices that the system (and the people within it) may make. We can listen to, learn from, and create space for ideas that are not part of the dominant ‘norm’.

As institutions, we can develop policies and practices that make implicit biases, perspectives and structures more transparent, committing resources (time, funding, people) to creating meaningful and lasting change through continuing professional development or other practices that lead to behaviour change. We can commit to resourcing training programs in education research that are built on and welcome pluralistic epistemologies.

We can legitimize those who speak out against power, confronting those who are aggressors within the Master’s House, rather than silencing or minimizing those who call out microaggressions or racist and sexist practices. Institutions can better support the work of the people leading these changes, fairly compensating people for their work as consultants or committee members by providing protected time, funding, space, and/or additional support. Finally, institutions need to dismantle the existing practices, rooted in the norms that hire, promote and reward singular demonstrations of zero point epistemology, making way for new ideas and leaders that can construct a more equitable system for change.

The journal in which this paper is published is itself an institution within our field. This paper was commissioned for a special issue in celebration of Dr. Geoffrey Norman who has just stepped down as Editor-in-Chief after 25 years (Norman and Ellaway 2020). As he himself would acknowledge, for a quarter of a century, Dr. Norman has guided this journal, shaped the stories that we have written and read, and curated the thoughts and perspectives bound between its pages. AHSE has always been a journal making way for new ideas; celebrating the advances of our fields, and moving us beyond the staid singular word. And for that, we thank Dr. Norman and also welcome new ideas and leaders to AHSE. We anticipate that whatever comes in the next quarter century will also encompass the plurality of stories that have not yet been written, not yet been heard, and not yet been read within these pages.

We do not claim to know how best to engage and embrace the many identities that are marginalized, oppressed, and erased. We have not always been successful in our demands that institutions and structures address the historical injustices to which they owe their power. We cannot even claim that there is agreement within the field of HPE that knowledge is not neutral and value-free, and that claiming otherwise just reinforces the power of the dominant group. Clearly, we have work to do. As we all, individually and collectively, try to breathe within this new space, where our perspectives of proximity, freedom, or safety may have shifted, we can choose not to re-erect the statues that are falling around us. Doing so will simply resurrect our past failures, writing the same stories of inequity and marginalization. We can dismantle the Master’s House and build a new one, one that is more equitable and inclusive. We must commit to this new beginning.

Author contributions

Ayelet Kuper, Morag Paton, and Thirusha Naidu framed the main conceptual ideas of the paper. Morag Paton, Ayelet Kuper, Thirusha Naidu, Tasha Wyatt, Cynthia Whitehead, and Stephanie Waterman contributed to the theoretical underpinnings. Morag Paton, Ayelet Kuper, Oluwasemipe Oni, Gianni Lorello, Umberin Najeeb, Zac Feilchenfeld contributed to the praxis section. The first draft of the manuscript was written by Morag Paton and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

BMO Financial Group Chair in Health Professions Education Research at University Health Network, Award Number: None | Recipient: Cynthia R Whitehead. Canadian Institutes of Health Research Operating Grant, Award Number: 287000 | Recipient: Cynthia R Whitehead. AMS Phoenix Project salary support. Recipients: Cynthia Whitehead, Ayelet Kuper. University of Toronto, General Internal Medicine (GIM) Mak Research Award, Award Number: None. Recipient: Ayelet Kuper.

Compliance with ethical standards

Conflict of interest

The author(s) declare that they have no competing interests.

Ethical approval

As this paper examined existing literature and did not involve human subject recruitment, ethics approval was not required.