The patient-physician relationship. Teaching the human dimensions of care in clinical settings

A modified Delphi approach to nurturing professionalism in postgraduate medical education in Singapore

INTRODUCTION

Nurturing professional identities instils behavioural standards of physicians, and this in turn facilitates consistent professional attitudes, practice and patient care. Identities are socioculturally constructed efforts; therefore, we must account for the social, cultural and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aimed to forward a programme to nurture professionalism among physicians in Singapore.

METHODS

A three-phase, evidenced-based approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created based on the findings of the SSR. Third, a modified Delphi approach, which involved local experts to identify socioculturally appropriate elements to nurture professionalism, was used.

RESULTS

A total of 124 articles were identified from the SSR; these articles revealed definitions, knowledge, skills and approaches to nurturing professionalism. Through the modified Delphi approach, we identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

CONCLUSION

The results of this study formed the basis for a holistic and longitudinal programme focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. The findings will be of interest to medical communities in the region and beyond.

Cultivating compassion in medicine: a toolkit for medical students to improve self-kindness and enhance clinical care

BACKGROUND

Compassionate care lies at the foundation of good patient care and is a quality that patients and providers continue to value in the fast-paced setting of contemporary medicine. Compassion is often discussed superficially in medical school curricula, but the practical aspect of learning this skill is often not taught using a formal framework. In the present work, the authors present an 8-session curriculum with a mindfulness-based approach to compassion that addresses this need. It is hypothesized that students in this curriculum will improve in their levels of compassion based on validated scales.

METHODS

The curriculum was delivered to fourth-year medical students at Renaissance School of Medicine at Stony Brook University who had just completed their clerkship year. It was developed as a customizable set of modules that could be delivered in various ways. The students were taught with evidence-based cognitive exercises followed by group discussions and written reflections based on compassion-focused thematic questions. All students completed a pre- and post-Self-Compassion Scale, Compassion Scale, and Toronto Mindfulness Scale. Students in this course were compared with students in different courses about non-clinical topics delivered at the same time. Wilcoxon Signed Rank tests and Mann Whitney U tests were used to assess potential associations between pre- and post-survey responses for the validated scales and subscales.

RESULTS

17 fourth-year medical students completed pre- and post-course tests, 11 participated in the compassion curriculum while 6 participated from the other courses. Before any of the courses began, all students performed similarly on the pre-test across all scales. The students in the compassion curriculum demonstrated a significant increase in their total Self-Compassion score by 8.7 [95% CI 4.3 to 13.2] points (p = 0.008), total Compassion score by 6.0 [95% CI 1.4 to 10.6] points (p = 0.012), and the curiosity component of the Toronto Mindfulness Scale by 4.4 [95% CI 1.0 to 7.7] points (p = 0.012). There was no statistically significant difference between pre- and post-tests among the non-compassion curriculum students in the aforementioned scales (p = 0.461, p = 0.144, p = 0.785, respectively).

CONCLUSIONS

Our results indicate that the students in our course developed an enhanced ability to engage in self-compassion, to understand the shared human experience, and to be motivated to act to alleviate suffering. Regardless of a program's existing compassion education, this customizable model allows for easy integration into a medical student's crowded curriculum. Furthermore, although teaching compassion early and often in a clinician's training is desirable, our study that targeted fourth-year medical students suggests an additional benefit of rekindling the loss of compassion well described in a medical student's clinical years.

Through the looking glass: qualitative study of critical care clinicians engaging in humanities

PURPOSE

Critical care medicine is facing an epidemic of burnout and consequent attrition. Interventions are needed to re-establish the medical field as a place of professional growth, resilience, and personal well-being. Humanities facilitate creation, reflection, and meaning-making, holding the promise of personal and community transformation. This study aimed to explore how clinicians engage with a humanities program, and what role and impact do the humanities play in their individual and collective journey.

METHODS

This is a qualitative study employing a phenomenological approach. Participants were faculty and trainees who participated in the program. Data consisted of (a) 60-h observations of humanities evenings, (b) more than 200 humanities artifacts brought by participants, and (c) 15 in-depth participant interviews. Data were analyzed inductively and reflectively by a team of researchers.

RESULTS

Participants were motivated to engage with the humanities curriculum because of past experiences with art, identifying a desire to re-explore their creativity to make meaning from their clinical experiences and a wish to socialize with and understand their colleagues through a different lens. The evenings facilitated self-expression, and inspired and empowered participants to create art pieces and re-engage with art in their daily lives. More importantly, they found a community where they could be vulnerable and supported, where shared experiences were discussed, emotions were validated, and relationships were deepened between colleagues.

CONCLUSIONS

Humanities may impact resilience and personal and community well-being by facilitating reflection and meaning-making of challenging clinical work and building bonds between colleagues.

Measurement of Humanity Among Health Professionals: Development and Validation of the Medical Humanity Scale Using the Delphi Method

BACKGROUND

Despite the importance of humanism in providing health care, there is a lack of valid and reliable tool for assessing humanity among health professionals.

OBJECTIVE

The aim of this study was to design a new humanism scale and to assess the validity of this scale in measuring humanism among Syrian health professional students.

METHODS

The Medical Humanity Scale (MHS) was designed. It consists of 27 items categorized into 7 human values including patient-oriented care, respect, empathy, ethics, altruism, and compassion. The scale was tested for internal consistency and reliability using Cronbach α and test-retest methods. The construct validity of the scale was also tested to assess the ability of the scale in differentiating between groups of health professional students with different levels of medical humanity. A 7-point Likert scale was adopted. The study included 300 participants including 97 medical, 78 dental, 82 pharmacy, and 43 preparatory-year students from Syrian universities. The Delphi method was used and factors analysis was performed. Bartlett test of sphericity and the Kaiser-Meyer-Olkin measure of sample adequacy were used. The number of components was extracted using principal component analysis.

RESULTS

The mean score of the MHS was 158.7 (SD 11.4). The MHS mean score of female participants was significantly higher than the mean score of male participants (159.59, SD 10.21 vs 155.48, SD 14.35; P=.008). The MHS mean score was significantly lower in dental students (154.12, SD 1.45; P=.005) than the mean scores of medical students (159.77, SD 1.02), pharmacy students (161.40, SD 1.05), and preparatory-year students (159.05, SD 1.94). However, no significant relationship was found between humanism and academic year (P=.32), university type (P=.34), marital status (P=.64), or financial situation (P=.16). The Kaiser-Meyer-Olkin test (0.730) and Bartlett test of sphericity (1201.611, df=351; P=.01) were performed. Factor analysis indicated that the proportion of variables between the first and second factors was greater than 10%, confirming that the scale was a single group. The Cronbach α for the overall scale was 0.735, indicating that the scale had acceptable reliability and validity.

CONCLUSIONS

The results of this study suggest that the MHS is a reliable and valid tool for measuring humanity among health professional students and the development of patient-centered care.

Role modelling in professional identity formation: a systematic scoping review

BACKGROUND

Role modelling's pivotal part in the nurturing of a physician's professional identity remains poorly understood. To overcome these gaps, this review posits that as part of the mentoring spectrum, role modelling should be considered in tandem with mentoring, supervision, coaching, tutoring and advising. This provides a clinically relevant notion of role modelling whilst its effects upon a physician's thinking, practice and conduct may be visualised using the Ring Theory of Personhood (RToP).

METHODS

A Systematic Evidence Based Approach guided systematic scoping review was conducted on articles published between 1 January 2000 to 31 December 2021 in the PubMed, Scopus, Cochrane, and ERIC databases. This review focused on the experiences of medical students and physicians in training (learners) given their similar exposure to training environments and practices.

RESULTS

12,201 articles were identified, 271 articles were evaluated, and 145 articles were included. Concurrent independent thematic and content analysis revealed five domains: existing theories, definitions, indications, characteristics, and the impact of role modelling upon the four rings of the RToP. This highlights dissonance between the introduced and regnant beliefs and spotlights the influence of the learner's narratives, cognitive base, clinical insight, contextual considerations and belief system on their ability to detect, address and adapt to role modelling experiences.

CONCLUSION

Role modelling's ability to introduce and integrate beliefs, values and principles into a physician's belief system underscores its effects upon professional identity formation. Yet, these effects depend on contextual, structural, cultural and organisational influences as well as tutor and learner characteristics and the nature of their learner-tutor relationship. The RToP allows appreciation of these variations on the efficacy of role modelling and may help direct personalised and longitudinal support for learners.

Thinking more wisely: using the Socratic method to develop critical thinking skills amongst healthcare students

BACKGROUND

In medicine, critical thinking is required for managing and tolerating medical uncertainty, as well as solving professional problems and treating diseases. However, the core of Confucianism, teacher-centered and exam-oriented settings in middle and high school education may pose challenges to developing critical thinking in Han Chinese or Taiwanese students. Students may be adversely affected by these pedagogies since student-centered settings were more effective in stimulating their critical and reflective thinking, as well as a sense of responsibility, in the ever-changing world. Therefore, guiding students with less stable foundations of critical thinking might require a different approach. A review article highlighted the potential utility of the Socratic method as a tool for teaching critical thinking in the healthcare field. The method involves posing a series of questions to students. More importantly, medical students and residents in clinical teaching are familiar with the method. Almost all healthcare students must complete a biochemistry laboratory course as part of their basic science training. Thus, we aimed to train students to develop critical thinking in the biochemistry laboratory course by using learning sheets and teacher guidance based on the Socratic method and questioning.

METHOD

We recruited second-year students from a medical school, of whom 32 had medical science and biotechnology majors (MSB), 27 had pharmaceutical science majors (PS), and 85 were medical undergraduate (MU) students. An exercise in critical thinking was conducted during a biochemistry laboratory course, which consisted of five different biochemical experiments, along with learning sheets that contained three or four critical thinking questions. Then, the teacher evaluated the students' ability to think critically based on nine intellectual dimensions (clarity, accuracy, precision, relevance, depth, breadth, logic, fairness, and significance) based on the universal intellectual standards developed by Prof. Linda Elder and Richard Paul. In the following analysis, regression models and multivariate analysis were used to determine how students improved over time, and trajectory analysis were carried out in order to observe the trends in students' critical thinking skills construction.

RESULTS

Clarity and logic dimensions were identified as the key elements to facilitate the development of critical thinking skills through learning sheets and teacher guidance in students across all three different healthcare majors. The results showed that metacognitive monitoring via Socratic questioning learning sheets have demonstrated potential encourage students to develop critical thinking skills in all dimensions. Another unique contribution of current study was present the heterogeneous learning patterns and progress trajectories of clarity and logic dimensions within classes.

CONCLUSION

Using the Socratic learning model could effectively develop students' critical thinking skills so they can more effectively care for their patients.

Developing an Equitable COVID-19 Pandemic Response: Lessons Learned From a Multisectoral Public Health Partnership in Guadalupe, Arizona

The COVID-19 pandemic has disproportionately impacted communities that are medically underserved across the United States, including the 6,700 Hispanic and Pascua Yaqui residents of Guadalupe, Arizona. In May 2020, Guadalupe experienced new COVID-19 cases at a rate 13.9 times as high as its surrounding county, urging town leadership to establish the Guadalupe Community Response Team (GCRT), a multisectoral network of community, academic, and public health partners. The objectives of the GCRT were to: (a) increase access to health and support services; (b) develop novel and intensive outreach efforts; and (c) build partnerships to strengthen public health capacity. From June 2020 to December 2021, the GCRT provided door-to-door case investigation and resource provision, coordinated testing and vaccination events, created public health communications, and developed COVID-19 guidance for cultural gatherings. These interventions were implemented in an effort to reduce community transmission of SARS-CoV-2 and increase equitable access to testing, vaccination, and social support resources. Cultural leaders, such as promotores de salud and Yaqui Cultural Specialists, were integral in building trust among community members. The GCRT provides valuable lessons learned on the importance of implementing a culturally grounded approach to COVID-19 mitigation to increase equitable access to health services during a public health emergency.

Medical teachers' affective domain teaching dilemma and path exploration: a cross-sectional study

BACKGROUND

In the student-centered modern teaching environment of higher education, the affective domain was of great value to the overall development of medical students and the sustainable development of medical education. However, in the teaching practice of the medical specialty in Our country, there are still a lot of phenomena that pay attention to knowledge teaching but neglect affective education. Compared with affective domain, teachers tended to focus on the learning of specialized knowledge and skills. This paper investigated the attitudes and evaluations of teachers and students of medical school on affective education, analyzed the current situation and problems of teaching in the affective educauion of medical professions, and explored the path of combining the affective field and medical profession from the perspective of medical teachers.

METHODS

A questionnaire survey was conducted among medical teachers and students across the country. Using the self-appointed teacher scale and the student scale to obtain their ratings of all dimensions of teaching in the affective field through a free online tool called "WenJuanXing". Descriptive statistics and multiple regression analysis methods were used to analyze the data to explore the obstacles in affective education and the factors affecting the outcome of affective education.

RESULTS

A total of 523 medical teachers and 3268 medical students were surveyed, according to the results of questionnaire data analysis, there are differences in the needs of senior and lower grade students in various dimensions of affective education, and the current Chinese medical teachers carrying out affective education are facing unclear positioning and interpretation of affective education goals, lack of affective experience in teaching methods, lack of affective education evaluation norms, lack of continuity and progressivity of affective cultivation, and school organizational mechanisms need to be improved.

CONCLUSIONS

This paper had some suggestions aimed at the above problem. Firstly, It is necessary to strengthen the construction of the organizational mechanism of medical universities, provide them with guarantees and training according to the characteristics of teachers of different teaching ages, and comprehensively improve teachers' affective literacy from the inside out. Secondly, teachers should design clear progressive goals and content systems of affective education, constructing an evaluation system of affective education in the experiential teaching method.

Learning from the implementation of clinical empathy training: an explorative qualitative study in search of the barriers and facilitators

BACKGROUND

Amid concerns about the decline of empathy during the clinical training of medical clerks, evidence that empathy improves patient outcomes suggests some potential for teaching empathy in ways that will affect the knowledge, attitude and behaviour of medical clerks. This potential alone cannot, however, guarantee the success of educational innovations to introduce empathy to the medical curriculum. This research aims to identify the barriers and facilitators of the implementation of a specific clinical initiative to enhance the empathy skills of clerks, namely the training of clerks to act as a 'MedGezel' or 'medical coach'.

METHOD

We conducted an explorative qualitative study based on interview data collected and analyzed using reflexive thematic analysis and the readiness for change theory. We conducted semi-structured interviews with relevant stakeholders in this particular qualitative study. Thematic analysis was based on open and axial coding using ATLAS.ti 9, which facilitated the emergence of common themes of interest and meaning for the study.

RESULTS

A total of 13 relevant stakeholders participated as interviewees in our study. The data was collected from April to June 2021. Our analysis generated 6 main themes which can provide insights into why the implementation of the MedGezel educational innovation failed so far. The following themes emerged: the case for change: why change?; practical necessity; leadership; management and resources; staff culture; and alignment with the corporate strategy.

DISCUSSION

The implementation failure can be partially explained as resulting from the personal attitudes and choices of participants, who struggled to reconcile a vision that they liked with side effects that they feared. While participants repeatedly mentioned management and leadership issues, these organizational issues seemed less important as they could be easily resolved in practice. What was more important and fatal for the initiative was its lack of alignment with staff culture, despite its alignment with corporate strategy.

CONCLUSION

This investigation into the barriers and facilitators influencing the implementation of the MedGezel program identified 6 explanatory themes, the most impactful one being staff culture.

In their own words: impact of donor information and personal statements on humanization of donors in a gross anatomy course

Humanization of donors in gross anatomy courses has been reported to facilitate professional behavior in healthcare students. However, there is a lack of research investigating whether students' knowledge of donor information is associated with humanization of whole body donors. To address this gap, the present study aimed to 1) determine whether knowledge of donor information is associated with greater humanization of donors and 2) investigate student perceptions of receiving donor information. Donor information was provided to students at the beginning of the course (cohort A) or at midsemester (cohort B). Questionnaires utilized quantitative and qualitative methods to assess humanization and student perceptions at the beginning, middle, and end of the semester. Independent t tests demonstrated that there was no statistically significant difference in mean humanization scores between cohorts A and B before the first dissection [t(37) = 0.449, P = 0.656], at midsemester [t(35) = -1.546, P = 0.131], or at the end of the semester [t(28) = 0.004, P = 0.997]. Thematic analysis demonstrated that as the semester progressed students' view of dissection as an invasion of privacy and the donor as a patient decreased. Themes delineated from students' open-ended responses revealed that students felt a connection with their donors; that the donors' consenting information gave permission to dissect; and that the information gave students an invaluable learning experience. Students demonstrated detached concern toward their donor, viewing the donor as a learning tool or educator rather than a patient. However, their responses also indicated the development of a deeper, personal connection to donors.NEW & NOTEWORTHY A look at the use of donor personal statements and information to humanize donors and how it influenced students' experiences in a gross anatomy laboratory.

Craving Empathy: Studying the Sustained Impact of Empathy Training on Clinicians

Evidence is sparse when it comes to the longitudinal impact of educational interventions on empathy among clinicians. Additionally, most available research on empathy is on medical trainee cohorts. We set out to study the impact of empathy and communication training on practicing clinicians' self-reported empathy and whether it can be sustained over six months. An immersive curriculum was designed to teach empathy and communication skills, which entailed experiential learning with simulated encounters and didactics on the foundational elements of communication. Self-reported Jefferson Scale of Empathy (JSE) was scored before and at two points (1-4 weeks and 6 months) after the training. Overall, clinicians' mean self-empathy scores increased following the workshop and were sustained at six months. Specifically, the perspective taking domain of the empathy scale, which relates to cognitive empathy, showed the most responsiveness to educational interventions. Our analysis shows that a structured and immersive training curriculum centered on building communication and empathy skills has the potential to positively impact clinician empathy and sustain self-reported empathy scores among practicing clinicians.

Intensity, dynamics and deficiencies of empathy in medical and non-medical students

BACKGROUND

Empathy is an important competence in the professional development of medical students. The purpose of our study was to compare the levels and scales of empathy in people studying in different educational strategies.

METHODS

The study was conducted between April 2019 and March 2020. Medicine, nursing, midwifery, physiotherapy, psychology, pedagogy and sociology students were the participants of this study. University students preparing for medical professions (n = 1001) and students of programs unrelated to medicine (n = 700) underwent the Empathy Quotient test (EQ-40). We have compared results in both study groups with the use of the distribution of density, analysis of variance and student's t-test.

RESULTS

The average results received by students of the university preparing for medical professions were lower (M = 42.6) than those of the non-medical university students (M = 45.3) and the differences between the universities turned out to be statistically important (t = - 5.15, df = 1699, p < 0.001). As many as 14.6% of the students in the 1st EQ class were preparing for various medical professions while 9% studied social sciences. 18.2% of all medical programme students (n = 412) manifested the lowest empathy class. Our research has revealed that the students with Asperger profile (AP) and high-functioning autism (HFA) studied at universities preparing for medical professions (n = 18) more frequently than at non-medical universities (n = 5).

CONCLUSIONS

We have noticed a serious indicator of erosion in the levels of empathy in medical students and an increase in the number of people with AP and HFA. Empathy decreases in students after the third year of their studies, regardless of the kind of university. We recommend an introduction of career counselling when specialization is being chosen.

Design and Initial Validation of a Humanistic Care Evaluation Tool

Objective

This study aimed at developing and validating a humanistic care tool in Anhui province that could be used across Chinese public hospitals, and to reflect the humanistic care from patients’ perspective.

Participants

A cross-sectional survey was conducted in three public hospitals of Anhui Province, China by adopting simple random sampling, which included 312 outpatients and 323 inpatients.

Methods

The dimensions of the tool were set according to “Further Improve Medical Service Action Plan” in China and Patient-Doctor Relationship Questionnaire. Cronbach’s alpha values were calculated and used to evaluate the reliability of this tool. Construct validity was tested by the exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The associations between characteristics and humanistic care were analyzed by binary logistic regression.

Results

These initial findings showed that about two-thirds of the respondents experienced humanistic care. Both the reliability and construct validity of the humanistic care evaluation tool were suitable Social aspects (location and yearly income), treatment style and having a regular doctor were significantly associated with better humanistic care (all P<0.05).

Conclusion

The humanistic care tool can directly reflect the humanistic care from patients’ perspective, and can be popularized and applied across Chinese public hospitals. These findings have important implications to further improve medical service in Chinese public hospitals.

How Doctors Do Things with Empathy in Online Medical Consultations in China: A Discourse-analytic Approach

It is widely acknowledged that doctors' expressions of empathy are fundamental to a successful medical consultation. While extensive work has been done on empathic communication in face-to-face medical encounters, few studies explored expressions of empathy in online medical consultations. Such research is particularly scarce in Chinese contexts, even though China has recently seen substantial growth in e-healthcare activities. To gain a better understanding of clinical empathic communication in online environment, this study, using discourse-analytic tools, explores the pragmatic functions of doctors' empathic responses in text-based online medical consultations in China. The study finds that most empathic responses by doctors can be said to perform the function of facilitating the institutional task of problem-solving, and a few serve the function of self-promotion that is likely to be triggered by the e-commerce model for online medical services.

Evaluation of soft skills among Italian Healthcare Rehabilitators: A cross sectional study

BACKGROUND

Healthcare rehabilitator skills can be grouped into hard and soft skills. Hard skills are specific and teachable, which can be defined and measured, while soft skills are less tangible and more difficult to quantify. The aim of this study is to investigate the level of knowledge of soft skills among Italian healthcare rehabilitators, and how they were acquired.

DESIGN AND METHODS

Two hundred healthcare rehabilitators, who worked in Southern Italy were enrolled from September 1st to October 31st 2017, and interviewed with Computer-Assisted-Web-Interview (CAWI) software, to assess their level of soft skills.

RESULTS

Healthcare rehabilitators showed significant satisfaction with university education (59.5%), particularly for theoretical training (64%), while significant dissatisfaction was found for technical-practical training (63.5%), training in patients' family management (66.5%) and stages participation to improve soft skills (59%). Dissatisfied rehabilitators were found for university education of soft skills (59%), particularly for interpersonal relationships with patients family (66.5%) and technical-practical train in(63.5%). Women considered the training courses about soft skills acquisition more useful than men (43.8%).

CONCLUSIONS

Healthcare rehabilitator training is lacking in the teaching of both technical-practical and soft skills. It is striking that in a healthcare profession like that of the rehabilitator, where practical and empathic skills are fundamental in the relationship with the patients, such skills are not treated in analogously with theoretical training.

Group Mentoring for Junior Medical Students-the Mentor in the Reflection Cycle

PURPOSE

To describe the experience and perceptions of physicians involved in group mentoring of undergraduate pre-clinical medical students.

METHOD

We conducted a cross-sectional questionnaire-based survey on perceptions of mentors regarding their motivation, personal development, reflective experience, and burnout. All the participants were mentors to undergraduate pre-clinical medical students in the course "Becoming a Physician." This unique course focuses on various aspects of medical professionalism and aims to increase awareness and sensitivity to patients, especially of disadvantaged populations, and to promote sensitive effective communication skills. Mentors in the course are expected to serve as role models to their students.

RESULTS

Of 36 mentors, 33 (91.7%) responded. The most frequent motivations to join the course were to contribute to students' personal, social, and professional development and to contribute to educating more compassionate physicians. The topics discussed most in the groups were the meaning of being a physician and ethical dilemmas. Mentors expressed that they gained professional growth and opportunities to reflect on the complexity of physicians' training and work. They perceived their highest success as being able to serve as role models for their students and provide them broad perspectives. Mentors stated that they failed in trying to facilitate content learning, and were disturbed by students' lack of punctuality. Group mentors scored relatively low on the Maslach Burnout Inventory for Physicians.

DISCUSSION

This study provides insights on the experience of mentorship of medical school students, and on mentors' perceptions regarding their teaching experience and personal and professional development.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-020-01146-1.

A Qualitative Study on the Experiences and Reflections of Junior Doctors During a Palliative Care Rotation: Perceptions of Challenges and Lessons Learnt

CONTEXT

Doctors caring for patients with life-limiting illness are often exposed to emotional distress.

OBJECTIVES

We aimed to explore the experiences and perceptions of junior doctors working full time in a palliative care rotation. We examined the lessons junior doctors learnt in managing their emotions as they face patients' death on a daily basis.

METHODS

We conducted a qualitative study with seven focus group discussions involving 21 junior doctors (medical officers and residents). Data were analyzed using qualitative thematic analysis to identify the themes related to the perceived challenges of these junior doctors and how they managed the struggles. Interviews were conducted with junior doctors who spent at least two months in a palliative care unit in a tertiary hospital or an inpatient hospice.

RESULTS

Junior doctors caring for dying patients in a palliative care rotation faced internal conflicts. Conflicting feelings arose because of differing expectations from their preconceived notions of their roles as doctors. Two main themes of internal struggles were professional distancing and emotional detachment as well as prognostic uncertainty and when to withhold and withdraw medical treatments. Coping strategies that helped included mentoring and role modeling provided by palliative care physicians, reframing their care experiences and reflection to find meaning in their work.

CONCLUSION

A palliative care rotation exposes junior doctors to emotionally overwhelming experiences. With proper guidance, this exposure is useful in teaching junior doctors important coping strategies, allowing learning to occur at a deeper level.

Communicating value to patients-a high-value care communication skills curriculum

INTRODUCTION

With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients.

OBJECTIVE

We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers.

METHODS

Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale.

RESULTS

70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%).

CONCLUSION

There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.

Unveiling the Hurdles in Cultivating Humanistic Physicians in the Clinical Setting: An Exploratory Study

Background

The importance of cultivating a humanistic physician has gained attention in medical education. Humanistic values are established in early education and medical schools should provide a suitable environment to nurture and grow these values into professional identity. The clinical setting has a significant impact due to its direct involvement of students in real-life situations.

Objectives

The present study aims to explore the hurdles in cultivating humanistic physicians in the clinical setting.

Methods

We conducted a qualitative study involving medical students in the clinical phase, as well as residents, clinical teachers, and module administrators in the clinical setting under study.

Results

Respondents from different groups of stakeholders shared the same definition for 'humanistic physician': a physician who provides patient-centred care while demonstrating empathy, respect, compassion, integrity, knowledge, competence and a collaborative spirit. Despite changes in the healthcare system and technological advancements, humanistic physicians are still needed.

Conclusion

Cultivating humanistic physicians is a complex process, requiring various methods and assessments. Role models play a significant role in this process, which included not only clinical teachers but also peers. Feedback from peers was perceived as an important factor. The key hurdles identified were negative role models, and a less humanistic learning environment and the students' personal backgrounds.

Learning from patients about patient-centredness: A realist review: BEME Guide No. 60

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes.Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness.Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory.Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusters - comparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisation - to show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness.Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.

Does clinical training period support patient-centeredness perceptions of medical students?

BACKGROUND

Learning environment influences students' professional formation and patient-centered attitudes and behaviors.

OBJECTIVE

The purpose of this study is to investigate how hidden curriculum of learning environment and the previous experience with chronically ill patients affect patient-centeredness perceptions of medical students.

DESIGN

We followed 144 students and determined their opinions on 'ideal patient-centered practice and learning environment' via patient-centeredness questionnaire (PCQ) just before (third year) and at the end (sixth year) of clinical training years of medical school. At the end of each clinical training year (fourth, fifth, and sixth years), we determined experiences of the students about 'patient-centeredness of the learning environment' using a relevant survey called communication, curriculum, and culture (C3) instrument. We also compared PCQ and C3 instrument scores of the participants who had chronically ill patient in their families/friends and who do not.

RESULTS

C3 scores worsened over the years, namely, students faced increasing number of examples against patient centeredness. Final PCQ scores were worse than initial ones. C3 and PCQ scores of the students who had previous experience with chronically ill patients were not different from the scores of the remaining students.

CONCLUSION

Medical students, even those who have a chronically ill patient in their families or friends, lose their idealism about patient centeredness to some degree possibly due to hidden curriculum of the medical school.

Educational roles as a continuum of mentoring's role in medicine - a systematic review and thematic analysis of educational studies from 2000 to 2018

BACKGROUND

Recent studies have gone to great lengths to differentiate mentoring from teaching, tutoring, role modelling, coaching and supervision in efforts to better understand mentoring processes. This review seeks to evaluate the notion that teaching, tutoring, role modelling, coaching and supervision may in fact all be part of the mentoring process. To evaluate this theory, this review scrutinizes current literature on teaching, tutoring, role modelling, coaching and supervision to evaluate their commonalities with prevailing concepts of novice mentoring.

METHODS

A three staged approach is adopted to evaluate this premise. Stage one involves four systematic reviews on one-to-one learning interactions in teaching, tutoring, role modelling, coaching and supervision within Internal Medicine, published between 1st January 2000 and 31st December 2018. Braun and Clarke's (2006) approach to thematic analysis was used to identify key elements within these approaches and facilitate comparisons between them. Stage two provides an updated view of one-to-one mentoring between a senior physician and a medical student or junior doctor to contextualise the discussion. Stage three infuses mentoring into the findings delineated in stage one.

RESULTS

Seventeen thousand four hundred ninety-nine citations were reviewed, 235 full-text articles were reviewed, and 104 articles were thematically analysed. Four themes were identified - characteristics, processes, nature of relationship, and problems faced in each of the four educational roles.

CONCLUSIONS

Role modelling, teaching and tutoring, coaching and supervision lie within a mentoring spectrum of increasingly structured interactions, assisted by assessments, feedback and personalised support that culminate with a mentoring approach. Still requiring validation, these findings necessitate a reconceptualization of mentoring and changes to mentor training programs and how mentoring is assessed and supported.

Illuminating exemplary professionalism using appreciative inquiry dialogues between students and mentors

PURPOSE

To explore the types of exemplary professional behaviors and the facilitators and barriers to professional behavior discussed by student-mentor dyads during appreciative inquiry (AI) dialogs.

MATERIALS AND METHODS

We conducted a qualitative analysis of AI narratives discussing exemplary professional practice written by third-year medical students following a dialog with mentors. Narratives were thematically analyzed using directed content analysis to explore the types of exemplary professional behaviors discussed and the facilitators and barriers to professional practice. Narratives were coded independently by two investigators; codes were finalized, themes were derived, and a model on how exemplary professional behaviors are nurtured and reinforced was developed.

RESULTS

Themes addressed humanism toward others and excellence, with altruism being an underlying implicit guiding principle behind professional behavior. Humanism toward self was infrequently discussed as an aspect of professionalism, but when discussed, was perceived to foster resilience. Principle-based attitudes and emotional intelligence facilitated professional behaviors. Programmatic scaffolds facilitated professional behavior and included curricula on reflective practice, mentorship, promoting learner autonomy and connectedness, and a safe environment.

CONCLUSIONS

AI is an effective strategy that can be used to stimulate learner reflection on professionalism, humanism, and wellness and promote learner acknowledgement of positive aspects of the learning environment.

Fostering Students' Collaborative Learning Competencies and Professional Conduct in the Context of Two Gross Anatomy Courses in Veterinary Medicine

Collaborative learning has been used in anatomy courses to support students' learning of challenging topics but the success of group work depends significantly on the students' ability to communicate in a professional manner. Veterinary students' experiences with tasks related to collaborative learning and professional conduct were studied by comparing learning collaborative competences and pedagogy, as well as perceived positive and challenging aspects, in two gross anatomy courses. Both qualitative and quantitative data were collected from students' experiences of course assignments and collaboration, as well as from self-evaluated collaboration competence development. Trying things out oneself, practical application and professional conduct were positively highlighted particularly in the first-year course (myology and arthrology) group work and learning from others more in the second year (topographical anatomy). Various group work challenges, often relating to practical matters or communication, were the key concerns for students. The main difference between the two courses in learning of collaborative knowledge work competencies appeared to relate to the nature of the group work assignment. The topography course included the element of collaboration in preparing a presentation and teaching session for the rest of the class. Interestingly, students on the myology and arthrology course gave more positive comments on professional conduct than the students on the topography course despite the fact that the latter course included more practical elements relating to their future profession.

How clinicians integrate humanism in their clinical workplace-'Just trying to put myself in their human being shoes'

INTRODUCTION

Humanism has been identified as an important contributor to patient care and physician wellness; however, what humanism means in the context of medicine has been limited by opinion and a focus on personal characteristics. Our aim was to describe attitudes and behaviours that enable clinicians to integrate humanism within the clinical setting.

METHODS

We conducted semi-structured individual interviews with ten clinical faculty to explore how they enact and experience humanism in patient care and clinical teaching. Interpretive description was used to analyze the data qualitatively.

RESULTS

Humanism in medicine was described through five themes representing core attitudes and behaviours: whole person care, valuing, perspective-taking, recognizing universality, and relational focus. Whole person care involved recognizing the multiple dimensions of personhood and sensitivity to others' needs; valuing involved respecting and appreciating others; perspective-taking consisted of considering others' perspectives, suspending judgment, and listening; recognizing universality involved acknowledging the shared human condition, finding common ground, transcending roles, and humility; and relational focus was described through multiple relationships between patients, families, clinicians and learners, becoming part of another's story, reciprocal influence, and accompaniment.

CONCLUSIONS

Whereas previous descriptions of humanism have focused on clinicians' personal qualities, our research describes a number of attitudinal and behavioural foundations of humanistic care and teaching, grounded in the experiences of clinical faculty. In drawing attention to the holistic and relational elements of humanism, our work highlights how these foundational elements can be more explicitly integrated into patient care, workplace culture, and clinical education.

Teaching & Learning Tips 4: Motivation and emotion in learning

Challenge: Trainees' motivational and emotional states can influence their learning and career decisions, but historically these "affective" learning factors have received little attention in medical education. In this "Tips" piece, we outline strategies to positively influence trainees' intrinsic motivation and emotion toward their training to ultimately enhance their overall learning experience.

Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice

BACKGROUND

Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction.

OBJECTIVE

To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians.

DESIGN

From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations.

PARTICIPANTS

Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors.

APPROACH

Participants' responses were analyzed using the constant comparative method.

KEY RESULTS

Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures.

CONCLUSIONS

While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.

Resident learning across the full range of core competencies through a transitions of care curriculum

The authors developed a Transitions of Care (TOC) curriculum to teach and measure learner competence in performing TOC tasks for older adults. Internal medicine interns at an academic residency program received the curriculum, which consisted of experiential learning, self-study, and small group discussion. Interns completed retrospective pre/post surveys rating their confidence in performing five TOC tasks, qualitative open-ended survey questions, and a self-reflection essay. A subset of interns also completed follow-up assessments. For all five TOC tasks, the interns' confidence improved following completion of the TOC curriculum. Self-confidence persisted for up to 3 months later for some but not all tasks. According to the qualitative responses, the TOC curriculum provided interns with learning experiences and skills integral to performing safe care transitions. The TOC curriculum and a mixed-method assessment approach effectively teaches and measures learner competency in TOC across all six Accreditation Council for Graduate Medical Education competency domains.

The Hidden Curricula of Medical Education: A Scoping Review

PURPOSE

To analyze the plural definitions and applications of the term "hidden curriculum" within the medical education literature and to propose a conceptual framework for conducting future research on the topic.

METHOD

The authors conducted a literature search of nine online databases, seeking articles published on the hidden, informal, or implicit curriculum in medical education prior to March 2017. Two reviewers independently screened articles with set inclusion criteria and performed kappa coefficient tests to evaluate interreviewer reliability. They extracted, coded, and analyzed key data, using grounded theory methodology.

RESULTS

The authors uncovered 3,747 articles relating to the hidden curriculum in medical education. Of these, they selected 197 articles for full review. Use of the term "hidden curriculum" has expanded substantially since 2012. U.S. and Canadian medical schools are the focus of two-thirds of the empirical hidden curriculum studies; data from African and South American schools are nearly absent. Few quantitative techniques to measure the hidden curriculum exist. The "hidden curriculum" is understood as a mostly negative concept. Its definition varies widely, but can be understood via four conceptual boundaries: (1) institutional-organizational, (2) interpersonal-social, (3) contextual-cultural, and/or (4) motivational-psychological.

CONCLUSIONS

Future medical education researchers should make clear the conceptual boundary or boundaries they are applying to the term "hidden curriculum," move away from general musings on its effects, and focus on specific methods for improving the powerful hidden curriculum.

Medical students and professionalism - Do the hidden curriculum and current role models fail our future doctors?

PURPOSE

Formal medical curricula aim to promote professionalism through learning from lectures, interactive tutorials and simulations. We report an exploratory voting exercise, conducted within a new integrated professional teaching module, examining the likely influence on students' knowledge and perceptions of truth telling.

METHODS

Responses were collected from cohorts of final year students over a six-year period. Students were asked to pick between two responses to a standardized clinical vignette, firstly the response that they personally thought was the more desirable action, and subsequently the response they believed would most likely result in the context of everyday real-life clinical practice.

RESULTS

The difference (proportional change) in voting for "avoid full disclosure" from vote 1 (more desirable action) to vote 2 (likely real-life response) was 50% (95% CI: 36-64%, p < 0.001) favoring avoidance of full disclosure.

CONCLUSIONS

This finding highlights a substantial inconsistency between the knowledge taught by the formal curriculum, and the perception generated by the hidden curriculum. Medical Schools should develop strategies to manage the hidden curriculum, prepare clinical teachers to be good role models, and prepare students to be discerning about the hidden curriculum and when choosing role models.

A Review of Empathy, Its Importance, and Its Teaching in Surgical Training

BACKGROUND

There has been much discussion in the medical literature about the importance of empathy and physician communication style in medical practice. Empathy has been shown to have a very real positive effect on patient outcomes. Most of the existing literature speaks to its role in medical education, with relatively little empiric study about empathy in the surgical setting.

OBJECTIVE

Review of empathy and its importance as it pertains to the surgeon-patient relationship and improving patient outcomes, and the need for increased education in empathy during surgical training.

METHODS

The published, peer-reviewed literature on patient-physician and patient-surgeon communication, medical student and resident education in empathy, and empathy research was reviewed. PubMed was queried for MESH terms including "empathy," "training," "education," "surgery," "resident," and "communication."

RESULTS

There is evidence of a decline in empathy that begins during the clinical years of medical school, which continues throughout residency training. Surgeons are particularly susceptible to this decline as by-product of the nature of their work, and the current lack of formalised training in empathic patient communication poses a unique problem to surgical residents.

CONCLUSIONS

The literature suggests that empathy training is warranted and should be incorporated into surgical residencies through didactics, role-playing and simulations, and apprenticeship to empathic attending role models.

Compassion Practices, Nurse Well-Being, and Ambulatory Patient Experience Ratings

BACKGROUND

Compassion practices both recognize and reward compassion in the workplace as well as provide compassionate support to health care employees. However, these practices represent an underexplored organizational tool that may aid clinician well-being and positively impact patient ambulatory care experiences.

OBJECTIVE

To examine the relationship between compassion practices and nursing staff well-being and clinic-level patients' experience ratings in the ambulatory clinic setting.

RESEARCH DESIGN

Surveys were collected from ambulatory nurses in January and February of 2015 in 30 ambulatory clinics affiliated with an academic medical center. Patient experience ratings were collected April to June of 2015.

SUBJECTS

One hundred seventy-seven ambulatory nurses (Registered Nurses, LPNs, medical assistants), as well as 3525 adult patients from the ambulatory clinics.

MEASURES

Ambulatory nurses assessed compassion practices, emotional exhaustion, and psychological vitality. Patient experience ratings were patient perceptions of courtesy and caring shown by nurses and patients' ratings of the outpatient services.

RESULTS

Compassion practices are significantly and negatively associated with nurse emotional exhaustion and positively associated with nurse psychological vitality. At the clinic-level, compassion practices are significantly and positively associated with patient perceptions of caring shown by nurses and overall patient ratings of the outpatient clinic. Supplemental analyses provide preliminary evidence that nurse well-being mediates the relationship between compassion practices and patient ratings of their care experience.

CONCLUSIONS

Our findings illustrate that compassion practices are positively associated with nurse well-being and patient perceptions of the care experience in outpatient clinics.

How Exemplary Teaching Physicians Interact with Hospitalized Patients

BACKGROUND

Effectively interacting with patients defines the consummate clinician.

OBJECTIVE

As part of a broader study, we examined how 12 carefully selected attending physicians interacted with patients during inpatient teaching rounds.

DESIGN

A multisite study using an exploratory, qualitative approach.

PARTICIPANTS

Exemplary teaching physicians were identified using modified snowball sampling. Of 59 potential participants, 16 were contacted, and 12 agreed to participate. Current and former learners of the participants were also interviewed. Participants were from hospitals located throughout the United States.

INTERVENTION

Two researchers-a physician and a medical anthropologist-conducted 1-day site visits, during which they observed teaching rounds and patient-physician interactions and interviewed learners and attendings.

MEASUREMENTS

Field notes were taken during teaching rounds. Interviews were recorded and transcribed, and code reports were generated.

RESULTS

The attendings generally exhibited the following 3 thematic behaviors when interacting with patients: (1) care for the patient's well-being by being a patient advocate and forming a bond with the patient; (2) consideration of the "big picture" of the patient's medical and social situation by anticipating what the patient may need upon discharge and inquiring about the patient's social situation; and (3) respect for the patient through behaviors such as shaking hands with the patient and speaking with the patient at eye level by sitting or kneeling.

CONCLUSIONS

The key findings of our study (care for the patient's well-being, consideration of the "big picture," and respect for the patient) can be adopted and honed by physicians to improve their own interactions with hospitalized patients.

A Multi-Institutional Longitudinal Faculty Development Program in Humanism Supports the Professional Development of Faculty Teachers

The authors describe the first 11 academic years (2005-2006 through 2016-2017) of a longitudinal, small-group faculty development program for strengthening humanistic teaching and role modeling at 30 U.S. and Canadian medical schools that continues today. During the yearlong program, small groups of participating faculty met twice monthly with a local facilitator for exercises in humanistic teaching, role modeling, and related topics that combined narrative reflection with skills training using experiential learning techniques. The program focused on the professional development of its participants. Thirty schools participated; 993 faculty, including some residents, completed the program.In evaluations, participating faculty at 13 of the schools scored significantly more positively as rated by learners on all dimensions of medical humanism than did matched controls. Qualitative analyses from several cohorts suggest many participants had progressed to more advanced stages of professional identity formation after completing the program. Strong engagement and attendance by faculty participants as well as the multimodal evaluation suggest that the program may serve as a model for others. Recently, most schools adopting the program have offered the curriculum annually to two or more groups of faculty participants to create sufficient numbers of trained faculty to positively influence humanistic teaching at the institution.The authors discuss the program's learning theory, outline its curriculum, reflect on the program's accomplishments and plans for the future, and state how faculty trained in such programs could lead institutional initiatives and foster positive change in humanistic professional development at all levels of medical education.

Using Health Impact Assessment as an Interdisciplinary Teaching Tool

Health Impact Assessment (HIA) courses are teaching public health and urban planning students how to assess the likely health effects of proposed policies, plans, and projects. We suggest that public health and urban planning have complimentary frameworks for training practitioners to address the living conditions that affect health. Planning perspectives emphasize practical skills for impacting community change, while public health stresses professional purpose and ethics. Frameworks from both disciplines can enhance the HIA learning experience by helping students tackle questions related to community impact, engagement, social justice, and ethics. We also propose that HIA community engagement processes can be enriched through an empathetic practice that focuses on greater personal introspection.

Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences With Cost-Conscious Care

PURPOSE

To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care.

METHOD

Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index.

RESULTS

Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001).

CONCLUSIONS

Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.

(How) do medical students regulate their emotions?

BACKGROUND

Medical training can be a challenging and emotionally intense period for medical students. However the emotions experienced by medical students in the face of challenging situations and the emotion regulation strategies they use remains relatively unexplored. The aim of the present study was to explore the emotions elicited by memorable incidents reported by medical students and the associated emotion regulation strategies.

METHODS

Peer interviewing was used to collect medical students' memorable incidents. Medical students at both preclinical and clinical stage of medical school were eligible to participate. In total 104 medical students provided memorable incidents. Only 54 narratives included references to emotions and emotion regulation and thus were further analyzed.

RESULTS

The narratives of 47 clinical and 7 preclinical students were further analyzed for their references to emotions and emotion regulation strategies. Forty seven out of 54 incidents described a negative incident associated with negative emotions. The most frequently mentioned emotion was shock and surprise followed by feelings of embarrassment, sadness, anger and tension or anxiety. The most frequent reaction was inaction often associated with emotion regulation strategies such as distraction, focusing on a task, suppression of emotions and reappraisal. When students witnessed mistreatment or disrespect exhibited towards patients, the regulation strategy used involved focusing and comforting the patient.

CONCLUSIONS

The present study sheds light on the strategies medical students use to deal with intense negative emotions. The vast majority reported inaction in the face of a challenging situation and the use of more subtle strategies to deal with the emotional impact of the incident.

Palliative Care Bedside Teaching: A Qualitative Analysis of Medical Students' Reflective Writings after Clinical Practices

CONTEXT

A mandatory course in palliative care (PC) is organized for all final-year medical students at the University of Navarre. It consists of 24 lectures, 4 workshops, and 1 scheduled five hour clinical PC service experience at two different sites. In the 48 hours after the visit and related to the clinical experience, each student has to complete a 500-word reflective writing (RW) piece.

OBJECTIVE

To investigate how a brief PC clinical experience helps equip the medical student.

METHODS

Qualitative study of RW. Two researchers produced a content analysis of students' RW. They collaboratively developed themes and categories with a constant review of the classification tree and an exhaustive collection of quotes. Differences between services were analyzed (λ²).

RESULTS

One hundred sixty-seven RW were analyzed from the 197 students on the course (response rate 85%). Six major themes emerged: All the students identified central aspects of PC work dynamics; students acquired specific PC knowledge (86%); the personal influence of the experience was reported (68%); students described how patients and their caregivers deal with the patients' illness (68%); students talked about the essence of PC and essential aspects of medicine (42%); students reported spontaneously having changed their assumptions about PC (15%); and they realized that the experience was relevant to all clinical practice. Categories such as teamwork, the expression of patients' and caregivers' feelings, and family devotion showed statistical differences between services (λ² p < 0.05).

CONCLUSION

A short bedside clinical experience in PC, encouraging student reflection, provides a deeper understanding of PC and even of core medicine values. The data we gather cannot explain only new skill acquisition but seems to suggest a life-changing personal experience for the student.

An objective structured clinical exam to measure intrinsic CanMEDS roles

BACKGROUND

The CanMEDS roles provide a comprehensive framework to organize competency-based curricula; however, there is a challenge in finding feasible, valid, and reliable assessment methods to measure intrinsic roles such as Communicator and Collaborator. The objective structured clinical exam (OSCE) is more commonly used in postgraduate medical education for the assessment of clinical skills beyond medical expertise.

METHOD

We developed the CanMEDS In-Training Exam (CITE), a six-station OSCE designed to assess two different CanMEDS roles (one primary and one secondary) and general communication skills at each station. Correlation coefficients were computed for CanMEDS roles within and between stations, and for general communication, global rating, and total scores. One-way analysis of variance (ANOVA) was used to investigate differences between year of residency, sex, and the type of residency program.

RESULTS

In total, 63 residents participated in the CITE; 40 residents (63%) were from internal medicine programs, whereas the remaining 23 (37%) were pursuing other specialties. There was satisfactory internal consistency for all stations, and the total scores of the stations were strongly correlated with the global scores r=0.86, p<0.05. Noninternal medicine residents scored higher in terms of the Professional competency overall, whereas internal medicine residents scored significantly higher in the Collaborator competency overall.

DISCUSSION

The OSCE checklists developed for the assessment of intrinsic CanMEDS roles were functional, but the specific items within stations required more uniformity to be used between stations. More generic types of checklists may also improve correlations across stations.

CONCLUSION

An OSCE measuring intrinsic competence is feasible; however, further development of our cases and checklists is needed. We provide a model of how to develop an OSCE to measure intrinsic CanMEDS roles that educators may adopt as residency programs move into competency-based medical education.

Impact of medical curriculum on conceptualization of professionalism by residents at a University Hospital, Jeddah, Saudi Arabia

BACKGROUND

The quality of healthcare outcomes and patient satisfaction are affected by communication skills and professionalism of the physician. Medical curricula have substantial influence on physicians' perception of professionalism.

OBJECTIVES

The aim of this study was to determine the impact of medical curriculum on the values of the residents at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, and their opinions on professionalism and to identify the sources that they describe as most influential in shaping their views.

METHODS

This cross sectional study was conducted in 2010/2011. A modified version of the questionnaire designed by Blue and colleagues was distributed among the target group (n=201). Psychometric analysis of the survey tool showed that it was precise and had construct validity.

RESULTS

The return rate was 76.6%. The overall means of the attitudes of both male and female residents toward the attributes of professionalism were low. Attitude toward professionalism showed an insignificant difference between male and female residents. Self-reflection ranked first among all studied attributes. Most male (80%) and female (76.7%) residents believed that working with consultants, specialists, and senior residents in the hospital was the main source of their opinions on professionalism. They considered basic science studies and the other extracurricular courses they attended to be the least helpful in developing their opinions.

CONCLUSION AND RECOMMENDATIONS

Residents at King Abdulaziz University Hospital feel underserved in the area of developing their values toward professionalism during the preclinical years, relying to some extent on their experiences during their clinical years and mainly on their interactions with consultants, colleagues, and hospital staff to develop their sense of professionalism. Given the recent changes in the curriculum adopted by the university, it is recommended to assess the attitudes of the students under the new curriculum toward professionalism and to compare them with those of students under the traditional curriculum.

Anatomy and humanity: Examining the effects of a short documentary film and first anatomy laboratory experience on medical students

Medical students begin their education inside a laboratory dissecting cadavers to learn human gross anatomy. Many schools use the course experience as a way to instill empathy and some have begun integrating video and recorded interviews with body donors to humanize the experience, but their impact has yet to be measured. This study examines the effects of a brief documentary film and the initial cadaver encounter on student perceptions and attitudes towards the laboratory experience. A pre-test, exposure, post-test design was used with 77 first-year medical students at the University of Central Florida. A previously validated questionnaire was adapted to measure attitudes, emotions, initial reaction to cadaver, perception of the donor as a person, and impressions of the film. An online questionnaire was completed before the first day of laboratory, in which students watched the film Anatomy and Humanity and handled their respective cadavers (no dissection was performed). The post-test was administered immediately following the activities of the first laboratory day. Results indicate an increase in negative attitudes towards dissection, but a more positive initial reaction to the cadaver than originally anticipated. Students also experienced a decrease in emotions like sadness and guilt regarding anatomy laboratory and were less likely to view the cadaver as a once-living person. Findings suggest a higher comfort level, but also greater detachment toward the cadavers from day one despite the video intervention. These results provide novel insight that may aid other interventions aimed at promoting humanism in the anatomy laboratory experience.

Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice

Recent calls for an expanded perspective on medical education and training include focusing on complexities of professional identity formation (PIF). Medical educators are challenged to facilitate the active constructive, integrative developmental process of PIF within standardized and personalized and/or formal and informal curricular approaches. How can we best support the complex iterative PIF process for a humanistic, resilient health care professional? How can we effectively scaffold the necessary critical reflective learning and practice skill set for our learners to support the shaping of a professional identity?The authors present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education (GME) at their institutions. These are (1) interactive reflective writing fostering reflective capacity, emotional awareness, and resiliency (as complexities within physician-patient interactions are explored) for personal and professional development; (2) synergistic teaching modules about mindful clinical practice and resilient responses to difficult interactions, to foster clinician resilience and enhanced well-being for effective professional functioning; and (3) strategies for effective use of a professional development e-portfolio and faculty development of reflective coaching skills in GME.These strategies as "bridges from theory to practice" embody and integrate key elements of promoting and enriching PIF, including guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, and creating collaborative learning environments. Ideally, such pedagogic innovations can make a significant contribution toward enhancing quality of care and caring with resilience for the being, relating, and doing of a humanistic health care professional.

Teaching and assessing professionalism in medical learners and practicing physicians

Professionalism is a core competency of physicians. Clinical knowledge and skills (and their maintenance and improvement), good communication skills, and sound understanding of ethics constitute the foundation of professionalism. Rising from this foundation are behaviors and attributes of professionalism: accountability, altruism, excellence, and humanism, the capstone of which is professionalism. Patients, medical societies, and accrediting organizations expect physicians to be professional. Furthermore, professionalism is associated with better clinical outcomes. Hence, medical learners and practicing physicians should be taught and assessed for professionalism. A number of methods can be used to teach professionalism (e.g. didactic lectures, web-based modules, role modeling, reflection, interactive methods, etc.). Because of the nature of professionalism, no single tool for assessing it among medical learners and practicing physicians exists. Instead, multiple assessment tools must be used (e.g. multi-source feedback using 360-degree reviews, patient feedback, critical incident reports, etc.). Data should be gathered continuously throughout an individual's career. For the individual learner or practicing physician, data generated by these tools can be used to create a "professionalism portfolio," the totality of which represents a picture of the individual's professionalism. This portfolio in turn can be used for formative and summative feedback. Data from professionalism assessments can also be used for developing professionalism curricula and generating research hypotheses. Health care leaders should support teaching and assessing professionalism at all levels of learning and practice and promote learning environments and institutional cultures that are consistent with professionalism precepts.

Teaching professional and humanistic values: suggestion for a practical and theoretical model

OBJECTIVES

To suggest and describe a practical and theoretical underpinning for teaching professional and humanistic values.

METHODS

The author describes four learning methods that together comprise a model for teaching professional and humanistic values. The author defends this model by citing evidence and relevant literature as well as his extensive experience with numerous colleagues in successfully applying the model in large scale programs.

RESULTS

The combination of teaching methods that comprise the model evolved over 30 years from the experience of several large collaborations with educators in teaching learners at all levels of medical education. The four teaching methods are (1) experiential learning of skills, (2) critical reflection, (3) a supportive group process, and (4) a sufficiently longitudinal curriculum. Together, these methods create a theoretical model with mutually reinforcing elements for enhancing commitment to core values and optimizing professional identity formation.

CONCLUSIONS

This paper describes the combined model and the methods in detail and reviews evidence favoring incorporation into curricula.

PRACTICE IMPLICATIONS

The combined model educationally enhances core values that underlie the professional identity formation of physicians. The model is practical and generalizable, and should be used by curriulum planners.