Third-Year Medical Students' Reactions to Surgical Patients in Pain: Doubt, Distress, and Depersonalization

"Do No Harm?" Moral Distress Among Medical Students During the Surgical Clerkship

OBJECTIVES

Moral distress, reported among healthcare workers across a variety of settings, is associated with negative mental health consequences, burnout, and intention to leave a position. The scant literature exploring medical students' moral distress does not specifically examine moral distress during the surgical clerkship nor does it characterize the type of moral distress experienced by medical students. Thus, we aimed to explore and characterize medical students' moral distress during the surgical clerkship.

SETTING/PARTICIPANTS

This study was conducted at the University of Michigan Medical School evaluating narrative essays written by 3 cohorts of students (2018-19, 2019-20, 2020-21) who completed the surgical clerkship during their third year of medical school.

DESIGN

Deductive content analysis was used to evaluate 180 narrative essays for the presence of moral distress using a 5-subcategorization schema developed by Morley et al. (constraint-distress, tension-distress, dilemma-distress, uncertainty-distress, and conflict-distress).

RESULTS

Four of the 5 sub-categories of moral distress (constraint-distress, tension-distress, dilemma-distress and uncertainty-distress) were identified in medical student essays. There were no examples of conflict-distress.

CONCLUSIONS

Medical students described 4 of the 5 sub-types of moral distress during their surgical clerkship. The sub-types of moral distress most often experienced by medical students are different than sub-types of moral distress previously reported among nurses, suggesting the varied roles and responsibilities of the healthcare team impact the scenarios most likely to present moral distress. Additionally, medical students were hesitant to raise concerns with their team when they experienced events discordant with their moral beliefs; they cited their position in the medical hierarchy, fearing implications on their future career, and perceived lack of knowledge and experience as factors limiting their willingness to share. Finally, this study identifies morally distressing scenarios as opportunities for transformative learning for medical students specifically in the realm of professional identity formation.

Revisiting the conceptualisation and implications of medicine's 'hidden curriculum'

In medical training and practice, our professional attributes, attitudes, perceptions, character traits and identities are fundamentally shaped by our lived experiences and observations in clinical and para-clinical settings instead of being inculcated through formal curriculum or classroom teaching. For instance, clinical acumen, communication skills and bedside manners are learnt through role modelling and experiential learning in the course of clinical rotations. Likewise, one's attitudes, professional behaviours and inclinations are often also influenced by direct/indirect observations of the actions of others in the medical fraternity in various clinical and non-clinical settings. This is also what is often termed as the 'hidden curriculum' of medicine. In this article, we sought to provide a practical conceptualisation of the hidden curriculum in medical training, which we describe as lived experiences and personal observations of medical trainees and residents in clinical and para-clinical spaces, which shape their perceptions of the medical profession (vocational identity and purpose), patients (patient-physician relationship) and colleagues (intra- and inter-professional relationships), with downstream implications on physician well-being and clinical decision-making. Although this idea of a 'hidden curriculum' has conventionally carried predominantly negative connotations in medical literature, we suggest that it is an inevitable part of medical education and practice, which, through deliberate regulation, can potentially be shaped to create more positive and meaningful effects in the professional development of medical trainees.

A systematic scoping review moral distress amongst medical students

BACKGROUND

Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students.

METHODS

The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion.

RESULTS

Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD.

CONCLUSIONS

MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.

Cognitive Dissonance in Laboratory Animal Medicine and Implications for Animal Welfare

People experience cognitive dissonance when they entertain 2 conflicting ideas at the same time. Cognitive dissonance may cause a negative emotional state, which can lead to engagement of compensation mechanisms to resolve the conflict. Here we describe a survey that explores cognitive dissonance in laboratory animal veterinarians and veterinary technicians and various ways in which veterinary staff manage dissonance associated with research animal use. Respondents-164 veterinarians and 145 veterinary technicians-were asked to rate their opinions of various statements on a sliding scale of 'strongly disagree' to 'strongly agree' or 'never' to 'always.' Statements assessed negative emotions (discomfort, powerlessness, frustration) and compensation mechanisms (devaluing, emotional distancing, shifting responsibility) as bases for inferring effects on welfare states of animals. Responses were evaluated overall and were compared according to level of training (veterinarian compared with veterinary technician), years of work experience (0 to 5, 6 to 10, greater than 10), and species tended (large, mixed, small species). Respondents strongly agreed that animal wellbeing and animal use in research were important. Respondents reported feelings of discomfort, powerlessness, and frustration associated with work. In addition, respondents reported feeling empowered to initiate changes affecting animal welfare. The most frequent compensation mechanism noted was shifting responsibility onto the IACUC and institutional rules. Devaluing the animals was another reported compensation mechanism. Responses to emotional distancing statements were divided. Survey responses supported the existence of cognitive dissonance associated with laboratory animal medicine. Potential negative and positive effects on animal welfare are discussed.