South Africa has an obligation to redress historical inequitable access to medical education. A variety of strategies have been used to both widen access as well as to increase the number of places in medical school; however, possibly uniquely in the world, the majority ethnic group in the country remains underrepresented in medicine.

While we may be on track to addressing equality in terms of offering everyone the same access to a place in medical school, the challenge now is to address equity, in other words to recognise that not all students start from the same place and that medical schools must therefore acknowledge and make adjustments to imbalances. This needs to be an ongoing process, requiring us to identify and overcome intentional and unintentional barriers arising from bias and systemic structures.

If we accept that learning is socially constructed, we see that anything that impacts, or is impacted by, the social has a consequence for learning. Learning theories and the medical education literature assist us in thinking about this—social cognitive learning (Bandura), transformative learning (Mezirow), situated learning (Wenger), growth mindset (Dweck), feedback literacy (Carless), and relational pedagogy (Hinsdale) among others, in particular how these play out in clinical learning where competence depends on learning in context (Eraut), authentic and structured vocational activities with the guidance of more expert others (Billett), and experience-based learning (Dornan).

Internationally, we see that in clinical environments, students suffer microaggressions, are subject to minority tax, and may experience shame triggers and promoters (Bynum 2020). Our own research conducted at Stellenbosch University showed that for final year medical students, there was a tension between expecting to be invited to participate in clinical work but not necessarily experiencing that. Students did not always have a sense of agency to ask to participate (Blitz, 2019). Participation requires a sense of belonging. “Fitting in is about assessing a situation and becoming who you need to be to be accepted. Belonging, on the other hand, doesn't require us to change who we are; it requires us to be who we are” (Brown, 2010).

So, how do organisations enable all students and staff to “be who they are”? The Macy Foundation (2020) suggests three important responses to addressing harmful bias, one of which relates to “culture change.” This includes training (response to microaggressions, being an upstander/ally, and anti-racism), but also requires “institutional response to discriminatory behaviours.”

In a piece in the “When I say …” series, we stated that rather than “doing diversity,” we aligned ourselves with diversity as an explicit value position—excellence in medical education and practice can only truly occur once historical obstacles are recognised and addressed, and the notions of belonging, inclusion and virtue in difference are authentically embraced. Ultimately, diversity efforts must be directed at “recalibrating” the system (Chiavarolli, 2020).

The majority group is privileged and as a manifestation of its power offers “others” (those who are different from them in a critical way) an opportunity to be represented in the majority group. However, when confronted by the realities of these “others,” members of the dominant cultural group tend to have a defensive, wounded, angry, or dismissive response—referred to as fragility. Our fragility should not prevent us from having courageous conversations about change. These discussions are not easy, but avoidance is even worse. As we prepare ourselves, we should heed the advice to stay engaged, expect to experience discomfort, encourage all to speak their truth, and expect and accept a lack of closure. Those with power and privilege have the capacity to change the culture. Is attending to the social learning environment the current “big ask”? Should teachers be encouraged and assisted to engage in courageous conversations with each other and with students?

The title of this conference was “Disrupted Medical Education - challenging the norms of medical education.” Disruption requires vulnerability. Are we, in medical education organisations and institutions, willing to be vulnerable and engage in real cultural change? I would like to remind us of Representative John Lewis' phrase “Never, ever be afraid to make some noise and get in good trouble, necessary trouble.” Widening participation was a necessary initial step, but now we need to work towards full participation. Here's to “making some good trouble” as we disrupt our norms to not just widen selection, but to nurture truly full participation.