The quest for normality.

In this editorial, the editor reflects on what 'going back to normal' means in the context of health professions education, and she suggests that pursuing normality may not be the best goal or outcome for health professions educators, learners, or researchers.

As many societies around the world are now behaving as if the COVID-19 pandemic is ending, there is much discussion in health professions education (HPE) circles about returning to ‘normal’ pre-pandemic practices and systems of training health professionals. For some this involves de-pivoting (or whatever we might call the reverse of a pivot) from online and remote learning and returning to face-to-face classroom or bedside learning. It also means, or it is hoped that it will mean, that healthcare systems will return to pre-pandemic practice patterns with the breadth of learning experiences they afforded. Given that we have gone through particularly troubling times in the past few years, such thinking is understandable. Except that COVID-19 is still here and it is still placing a load on the healthcare system (although how much and in what ways varies according to time and context), many frontline healthcare providers are feeling burned out, and most healthcare systems have a large backlog of non-critical care to work through. Societies too may need or wish to find their way back to more normal (or less abnormal) relationships with their healthcare systems.

Despite this ambient desire for normalcy, it may be that there is no ‘normal’ on the horizon for HPE. Not only will overstretched and exhausted healthcare systems be unlikely to get ‘back to normal’ for some time, the consequences of the past two years during which most of our learners had distinctly abnormal training experiences is likely to reverberate through our healthcare and educational systems for some time to come. Even if we did see some miraculous return to normality, the tensions between the healthcare system and those who protested its vaccines and other protective measures will not go away, nor will the need to prepare for further waves of COVID-19 let alone the pandemics to come. Even if we could set aside the fallout from COVID-19, the challenges of climate change, of conflict and the threat of conflict, of economic uncertainty, of struggles over equity for marginalized and oppressed populations, and of the spreading ideology-driven legislative agendas that outlaw healthcare providers as well as their services, make it unlikely that we will find a way to any real normality in HPE any time soon. The burden of how to respond to this will fall to institutions and their leaders to resolve and I wish them well in their endeavours. But, as this as an academic journal, let us consider what this elusive normality might mean for Advances, for the field, and for academic publishing in general.

From one perspective, the ongoing instability could offer many opportunities for scholars to study systems and the individuals within them while under duress. But I find this has an uneasy feel of ‘a good day to bury bad news’ about it, and one would have to challenge the ethics of what could become an academic feeding frenzy at a time when many of our colleagues are struggling to get from one day to the next. The principle of primum non nocere (first do no harm) is a way of guiding researchers in this regard. I might argue therefore that we should not put extra burdens on those already overloaded, and that we should instead try to find ways to mitigate the stresses and struggles rather than adding to them.

From another perspective, we might anticipate that ongoing uncertainty might make it harder to conduct research. Deaneries and programs seem keen to protect their learners and their programs against additional unnecessary stressors, which could include the pursuit of educational research. Moreover, since our current contexts are so far from normal and they continue to change, the relevance and applicability of research conducted at a particular time or in a particular place may not extend far. Of course, I could equally argue that research that was conducted in earlier ‘normal’ contexts has less relevance in these uncertain times. This is not a uniform concern though as we know that for some research topics context matters less (such as cognition and procedural skills) than it does for others (such as professional identity formation and resilience). Care, critical thinking, and deep perspective are needed in negotiating these questions. Our ongoing uncertainty might also be shaping the kinds of scholarship being pursued. As an example, although I do not have data to back this up, my impression is that many scholars turned their hand to systematic and other kinds of reviews during the pandemic as a form of scholarship that can be conducted while working from home. Whether this persists, or whether other systemic artefacts will be identified in scholarly practices, we will have to see.

At Advances, a return to normal in HPE scholarship could mean us returning to pre-pandemic rates of submission, and we have seen a small reduction in the number of submissions over the last 6 months. If this continues, it could mean our editors and reviewers might have more bandwidth for their work with the Journal. Again, we will have to see. A return to normal may mean we might see a drop in the numbers of papers about COVID-19 and its impacts on HPE being submitted. That does not seem likely either, not least for the reasons we mentioned in a 2020 editorial where we asked that COVID-related educational science be substantial and measured, things that take time. (Ellaway et al., 2020) Indeed, it seems quite likely that the substantive HPE COVID studies have yet to be completed, let alone submitted or published. For these reasons and many others, normal seems elusive at Advances too.

So, what is normal, should we want it, can we get to it, or might normal be a fleeting illusion that will forever be beyond our grasp? Normal can mean many things. It can mean an ideal or a balance, such as normal blood pressure . It can mean habitual, such as normal practice hours or a normal order at a regularly frequented cafe. It can have a particular technical meanings such as normal distributions in statistics or in norm-referenced assessment. Normal can also be used as a way of excluding or othering people by defining some identities, practices, or beliefs as normal and all others as abnormal relative to an arbitrary norm. This is a major concern of disability theorists and activists, both in terms of the social manipulation of norms and in terms of the disabling consequences of socially imposed articulations of normality. (Siebers, 2008) Indeed, assumptions and assertions of normality by one group typically disables or excludes others. (Criado Perez, 2019) We should be careful therefore in thinking about or pursuing normality, we should be clear whose normal it is we are pursuing, and we should be clear who might lose as well as win from any such pursuit. For instance, the growing moral panics against LGBTQ + peoples, refugees, and racialized minorities we have been seeing around the world have been anchored in divisive concepts of normality, which cannot be accommodated or resolved by a return to normalities that are themselves contested. Quite how HPE programs will respond to challenges based on ideological normalities clearly needs to be better understood.

Even where normality is not used as a tool of oppression and control, normal as in common sense can just be another name for bias and prejudice. Normal in this way may support orthodoxies in scholarship such as: ‘this the normal way we use this methodology or theorise about this topic’. We should be mindful of established practice but as scholars we need to be able to adapt and change our approaches, to cross lines, and to embrace Dewey’s call for the ’audacity of the imagination’ in research practices.

I do think we therefore have to ask whether we really want a return to normal in HPE. Might a return to normal not shut down some of the difficult and yet critical conversations we have been having (or we have been trying to have) in HPE? Might a return to normal reassert systems of power and privilege we might prefer to put behind us? Might a return to normal reflect tired thinking and practices that we were so keen to move on from? Might a return to normal mean that we learned so little from the past few years that going back really was our only option? As a scholar and an editor, I am and I have to be invested in the unknown, in the possibility of new thinking, knowledge, and even wisdom. Although I and the editors of this Journal must act as stewards of the integrity and history of our field and of science in general, our attention must be on what is happening now and what will happen next. And so, I would argue, should you as a coparticipant in this strange and wonderful field of ours.

Of course, we can and should recover or re-establish those things we have lost that still have value, such as face-to-face meetings, participation in nonvirtual scholarly communities, and the serendipitous collegiality they afford. But even here balance is needed. Do we really need to jet around the world in the context of global climate change? Where will our new normal be in respect of responsible and proportionate academic engagement? We can also anticipate returning to conducting research that involves direct human contact. Except that too needs balance and care in these changed and changing times.

We should certainly try to help those who are burned out, traumatized, or otherwise still suffering the impacts of the pandemic to recover and re-establish what might be closer to a normal (i.e., balanced) way of working. We should work to address the disruptions of the pandemic years, and to learn what we can from them. We should also seek to re-establish trust and confidence in a world that has at times seemed fraught with danger and instability. But none of these things mean we have to embrace the old normal, none of them mean we need to simply roll things back to the way they were. After all, rolling things back to some past ideal (for the few) is what many reactionary forces are trying to do (and are often succeeding in doing) around the world, to the dismay and suffering of others. While not all burdens are opportunities, and while not all oppressions can provide sufficient inspiration to push back and rise above, this is a time when habit and orthodoxy will not suffice.

Either way, on behalf of Advances, I look forward to seeing new perspectives, new methods, new theories, new approaches, and new critiques of, in, and around the training of health professionals. I look forward to seeing the deep learning, the innovations, and the new debates this can engender. I look forward to the fresh perspectives and energy of new scholars as well as new insights from established scholars. I look forward to the field moving forward rather than falling back. Maybe we can all do better than normal.

SNAPP: we are moving!

Speaking of change, our publisher, Springer, is in the process of introducing a new editorial management system called SNAPP. I would ask, on behalf of the Journal, that authors bear with us as we make the transition from the old system to the new. We would also be keen to receive your feedback on your experiences with the new system in pursuit of increasing the robustness and efficiency of our peer review and publication processes.