From competencies to human interests: ways of knowing and understanding in medical education

Building on Strengths: An Affirmational and Systems-Level Approach to Revisiting Character in Medicine

ABSTRACT

Although U.S. medical education has continued to place increased emphasis on defining competency standards and ensuring accountability to the public, health care inequities have persisted, several basic health outcomes have worsened, public trust in the health care system has eroded, and moral distress, burnout, and attrition among practicing physicians have escalated. These opposing trends beg the question of how the "good doctor" concept may be strengthened. In this perspective, the authors argue that revisiting the construct of physician character from an affirmational perspective could meaningfully improve medical education's impact on overall health by more holistically conceptualizing what-and who-a good doctor is. The authors introduce positive psychology's framework of character strengths, probe the distinction between character strengths and medical professionalism, and summarize the role of character strengths in promoting physician engagement and well-being in health care work. They contend that a systems-level approach to cultivating character strengths will foster physician moral agency and well-being and, by extension, transformational change in health care. Consistent with best practice in modern character education, the authors propose that institutions mindfully cultivate moral community among all stakeholders (students, faculty, staff, postgraduate trainees, and patients) and that moral community interaction centers on each member's personal aspirations with respect to living a good life, guided by the character strengths framework and informed by patient perspectives.

Twelve tips on creating and using custom GPTs to enhance health professions education

The custom GPT is the latest powerful feature added to ChatGPT. Non-programmers can create and share their own GPTs ("chat bots"), allowing Health Professions Educators to apply the capabilities of ChatGPT to create administrative assistants, online tutors, virtual patients, and more, to support their clinical and non-clinical teaching environments. To achieve this correctly, however, requires some skills, and this 12-Tips paper provides those: we explain how to construct data sources, build relevant GPTs, and apply some basic security.

From skillful to empathic: evaluating shifts in medical students' perceptions of surgeons through a combined patient as teacher and arts-based reflection program

Introduction

The purpose of this study was to identify whether the incorporation of a combined Patient as teacher (PAT) and arts-based reflection (ABR) program during a surgical clerkship rotation could influence more humanistic perceptions of surgeons, using an innovative evaluation approach.

Methods

A novel, single question evaluation tool was created. Third year medical-students were asked to "list the top 5 attributes of a surgeon, in order of perceived importance" both before and after their surgical clerkship rotations and participation in the PAT/ABR program. Attributes identified by students were coded as either "humanistic" or "non-humanistic," which were then analyzed using generalized linear regression models under a Bayesian framework.

Results

After participation in the PAT/ABR program, the predicted probability of students ranking a humanistic characteristic as the most important attribute of a surgeon had increased by 17%, and the predicted probability of students ranking a humanistic characteristic amongst their top three attributes for a surgeon had increased by 21%.

Conclusion

This innovative evaluative method suggested the success of a combined PAT/ABR program in encouraging a humanistic perspective of surgery and this approach could potentially be explored to evaluate other humanistic education initiatives.

Graphic Novels and Comics in Undergraduate and Graduate Medical Students Education: A Scoping Review

There is an increasing use of graphic novels and comics (GnCs) in medical education, especially-but not only-to provide students with a vicarious learning experience in some areas of clinical medicine (palliative care, difficult communication, and rare diseases). This scoping review aimed to answer questions about how GnCs are used, the theories underlying their use, and the learning outcomes. Twenty-nine articles were selected from bibliographic databases and analyzed. A thematic analysis revealed four many themes: learning outcomes, students' reactions, theories and methods, and use of GnCs as vicarious learning. GnCs can support the achievement of cognitive outcomes, as well as soft skills and professionalism. The reactions were engagement and amusement, but drawing comics was also perceived as a protected space to express concerns. GnCs proved to be a possible way to provide a vicarious experience for learning. We found two classes of theories on the use of GnCs: psychological theories based on the dual concurrent coding of text and images and semiotics theories on the interpretation of signs. All the studies but two were single arm and observational, quantitative, qualitative, or mixed. These results suggest that further high-quality research on the use of GnC in medical training is worthwhile.

Teaching critical reflection in health professions education with transformative-vygotskian praxis

Reflective practice is a complex concept to adequately describe, communicate about and, ultimately, teach. Unrelieved tensions about the concept persist within the health professions education (HPE) literature owing to reflection's diverse theoretical history. Tensions extend from the most basic, e.g., what is reflection and what are its contents, to the complex, e.g., how is reflection performed and whether it should be evaluated. Nonetheless, reflection is generally seen as vital to HPE, because it imparts crucial strategies and awareness to learners in their professional practices. In this article, we explore both conceptual and pedagogical dimensions of teaching for reflection. We address the concept of reflection, its application to practice, and how to remain faithful to transformative, critical pedagogy when teaching for it. We present (a) an analysis of two theories of education in HPE: Transformative Learning and Vygotskian Cultural Historical Theory. We (b) outline a pedagogical approach that applies Piotr Gal'perin's SCOBA: schema for the complete orienting basis of an action. We then employ (a) and (b) to provide affordances for developing materials for educational interventions across HPE contexts.

Physician-Patient Communication Course: When the Inauguration of a New Israeli Medical School Coincided with COVID-19 Pandemic

Purpose

The curriculum of the Adelson School of Medicine at Ariel University, the newly established sixth medical school in Israel, includes a simulation center-based extended course on physician-patient communication, aiming to help students master the core competency of interpersonal and communication skills. For more than a year following the emergence of the COVID-19 pandemic, the school suspended most face-to-face (F2F) encounters, transforming most teaching activities to remote platforms. The paper outlines the ways we adapted teaching of this course to these circumstances, the reactions of students and mentors to the changes and results of 1st year students' survey.

Methods

During the lockdown in the first year 48 of 70 first-year students participated in a voluntary anonymous online evaluation of the course assessing motivation to become a physician; perceptions, feelings and attitudes towards the communication course, and advantages and disadvantages of online and F2F medical interviews.

Results

46.1% of the responding students reported that the pandemic strengthened their desire to become physicians. 56.3% claimed that they were able to a relatively large extent to empathize with COVID-19 patients who were exposed to the virus; 79.1% viewed their mentors as positive role models of communication skills. The students were able to receive and offer social support to their peers. They evaluated very highly the short instructional videos produced by the faculty.

Conclusion

During the lockdown, the respondents generally indicated positive attitudes towards the communication course, the mentors and the inclusion of physician-patient communication as a topic in medical education. The students and mentors reported many disadvantages and few advantages of remote learning. Yet inevitably remote learning including online-based simulations is a step towards preparations for future practice within virtual medical care and telemedicine. The limitations of this study include the cross-sectional design, small sample size and self-reporting.

Empathy across cultures - one size does not fit all: from the ego-logical to the eco-logical of relational empathy

Empathy is extolled in Western healthcare and medical education as an exemplary quality to cultivate in trainees and providers. Yet it remains an elusive and inadequately understood attribute. It posits a "one size fits all" unidimensional attribute applicable across contexts with scant attention given to its multifaceted dimensions in intercultural contexts. In this article, we uncloak the shortcomings of this conventional empathy in intercultural settings, and instead propound an expanded "relational empathy".

Student-led clinic cervical cancer screening-medical students' views on progression of learning, quality of Pap smears and women´s experiences of the visit - a mixed methods study

BACKGROUND

Student-led clinics (SLC) have been described, but not in gynecology. Gynecology is a subject typically covered in the last terms of medical training, however it includes few opportunities for students to tackle all phases of a consultation and a shortage of opportunities to perform gynecological examinations. Therefore, we started a student-led clinic for cervical cancer screening (SLC-CCS) in Linköping, Sweden and aimed to evaluate students' views on the progression of learning, the quality of the Papanicolaou (Pap) smear, and women´s experiences of the visit, using mixed methodology.

METHODS

The implementation of the SLC-CCS is described in detail. Students (n = 61) taking part in the SLC-CCS between January and May 2021 were invited to participate in a follow-up discussion (n = 24) focused around four themes: attitudes and expectations prior to participation, experiences of the patient encounter, organization of the placement, and reflections on and suggestions for further development of the placements. The group meetings were conducted in Swedish, recorded, transcribed verbatim and subjected to a qualitative, descriptive thematic analysis. Thematic analysis is considered an appropriate method of analysis for seeking to understand experiences, thoughts, or behaviors across a data set. The proportion of Pap smears lacking cells from the squamous epithelium during the study period was compared with data from the same clinic before the SLC-CCS started. A validated questionnaire on women's experience of the Pap smear visit was provided. Answers were compared between women who had the Pap smear taken by a student or a healthcare provider.

RESULTS

Three different themes were generated: growing confidence in the clinical situation, embodied awareness of variation in anatomy, doubting accuracy of one's own performance. The percentage of Pap smears lacking cells from the squamous epithelium were equal (2%) during the study period compared to the period before the SLC-CCS started (p = 0.28). No difference was found in the satisfaction index between the women examined by a student, those examined by a healthcare provider, or women who did not know who the examiner was (p = 0.112).

CONCLUSIONS

The students expressed a growing confidence in the clinical situation and there was high satisfaction from the women. The quality of the Pap smears taken by the students was equal to the quality of those taken by the health care staff. All these findings indicate that high patient safety was maintained during this activity support the recommendation to include SLC-CCS as part of the medical training.

Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study

Moral distress is common among critical care physicians and can impact negatively healthcare individuals and institutions. Better understanding inter-individual variability in moral distress is needed to inform future wellness interventions.

OBJECTIVES

To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress.

DESIGN

Interview-based qualitative study using inductive thematic analysis.

SETTING AND PARTICIPANTS

Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians.

RESULTS

Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians.

CONCLUSIONS AND RELEVANCE

An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.

Evaluation of learning outcomes of humanities curricula in medical students. A meta-review of narrative and systematic reviews

Objectives

To assess the expected learning outcomes of medical humanities subjects in medical studies curricula. To connect those expected learning outcomes with the types of knowledge to be acquired in medical education.

Methods

Meta-review of systematic and narrative reviews. Cochrane Library, MEDLINE (Pubmed), Embase, CINAHL, and ERIC were searched. In addition, references from all the included studies were revised, and the ISI Web of Science and DARE were searched.

Results

A total of 364 articles were identified, of which six were finally included in the review. Learning outcomes describe the acquisition of knowledge and skills to improve the relationship with patients, as well as the incorporation of tools to reduce burnout and promote professionalism. Programs that focus on teaching humanities promote diagnostic observation skills, the ability to cope with uncertainty in clinical practice, and the development of empathetic behaviors.

Conclusion

The results of this review show heterogeneity in the teaching of medical humanities, both in terms of content and at the formal level. Humanities learning outcomes are part of the necessary knowledge for good clinical practice. Consequently, the epistemological approach provides a valid argument for including the humanities in medical curricula.

Combining adaptive expertise and (critically) reflective practice to support the development of knowledge, skill, and society

Adaptive expertise (AE) and reflective practice (RP), two influential and resonant theories of professional expertise and practice in their own right, may further benefit health professions education if carefully combined. The current societal and systemic context is primed for both AE and RP. Both bodies of work position practitioners as agentive, learning continually and thoughtfully throughout their careers, particularly in order to manage unprecedented situations well. Similar on the surface, the roots and practices of AE and RP diverge at key junctures and we will focus on RP's movement toward critically reflective practice. The roots of AE and RP, and how they relate to or diverge from present-day applications matter because in health professions education, as in all education, paradigmatic mixing should be undertaken purposefully. This paper will explore the need for AE and RP, their shared commitments, distinctive histories, pedagogical possibilities both individually and combined, and next steps for maximizing their potential to positively impact the field. We argue that this exploration is urgently needed because both AE and RP hold much promise for improving health care and yet employing them optimally-whether alone or together-requires understanding and intent. We build an interprofessional education case situated in long-term care, throughout the paper, to demonstrate the potential that AE and RP might offer to health professions education individually and combined. This exploration comes just in time. Within the realities of uncertain practice emphasized by the pandemic, practitioners were also called to act in response to complex and urgent social movements. A combined AE and RP approach, with focus on critically reflective practice in particular, would potentially prepare professionals to respond effectively, compassionately, and equitably to future health and social crises and challenges.

Examining the Impact of Dialogic Learning on Critically Reflective Practice

PURPOSE

While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies.

METHOD

In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective.

RESULTS

The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences.

CONCLUSIONS

The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

The Powers of a Fish: Clinical Thinking, Humanistic Thinking, and Different Ways of Knowing

How are ways of knowing similar between clinical reasoning and the humanities, and can the latter be used to elucidate the former? This commentary considers a conceptual model proposed by Prince and colleagues in this issue to explore the different ways of knowing in art and medicine. Their proposed model links 2 approaches to clinical reasoning with an analytic approach said to be characteristic of the humanities-visual thinking strategies (VTS)-to teach skills in clinical reasoning. They suggest that the VTS approach aligns well with the 2 clinical reasoning approaches and use this relationship to argue for the introduction of the humanities into graduate medical education. However, is VTS truly an exemplar of analytic approaches used in the humanities? The approach to clinical decision making is a version of what Donald A. Schön calls technical rationality, but what is the epistemology used in the humanities and art? This commentary explores this question through the perspective of hermeneutics, a branch of philosophy that centers on an interpretive understanding of art, and through art, a way of knowing the self, others, and the world. In contrast to limiting the focus of the humanities in medical education to sharpening the powers of observation and analytical thinking, the author argues that art also offers a way to explore the challenges and triumphs of providing care to those in need and to explore the meanings, feelings, and experiences of living and dying. It offers a way of understanding and expressing the moral dilemmas of our time that aspires toward the aesthetic, philosophical, and existential truths of a life in medicine.

Linking the Humanities With Clinical Reasoning: Proposing an Integrative Conceptual Model for a Graduate Medical Education Humanities Curriculum

Discussion surrounding the role of the humanities as an important analytic epistemology within medical education is generally less robust than literature supporting its value in building empathy and promoting personal reflection and wellness. As such, the humanities have not been considered to be as relevant when teaching medical reasoning or technical skills. Yet, might the humanities offer value in emboldening the analytic thinking of medical learners? This article proposes an integrative conceptual model that links the thought process defining medicine-clinical reasoning-with humanistic analysis in an effort to advance the argument that the humanities offer a complementary and innovative platform that can be used within traditional medical education. The article then discusses preliminary findings from a pilot curriculum based on this model, implemented during internal medicine morning report at the University of North Carolina at Chapel Hill School of Medicine. Preliminary qualitative analysis of transcripts from the pilot curriculum demonstrates that a thought process analogous to that of clinical reasoning can be identified within guided group analyses of humanities works. Participants simultaneously used thought processes that were analytic and intuitive. The emergence of ambiguity/intuition as a theme in the pilot curriculum suggests the humanities could be a powerful tool for exploring and embracing ambiguity in clinical practice. Through the development of an integrative conceptual model, this article helps to demonstrate more explicitly the theoretical link between the reasoning pathways of the humanities and clinical medicine. Though a refined curriculum and more rigorous analysis are needed before arguing for the incorporation of the humanities into traditional graduate medical education on a larger scale, the preliminary findings here support the feasibility and promise of a curriculum based on the proposed integrative conceptual model.

Do We Need to Close the Door on Threshold Concepts?

ISSUE

Threshold Concepts are increasingly used and researched within health professions education. First proposed by Meyer and Land in 2003, they can be defined as ways of knowing central to the mastery of a subject. They are framed as profoundly transformative, impacting the identity of those who encounter them through irreversible shifts in an individual's outlook. Although Threshold Concepts have been identified in a multitude of educational settings across the continuum of health professions education, there has been little critique of Threshold Concepts as a theory of health professions education. Within adjacent fields critical discourse is also underdeveloped, perhaps given the educational resonance of the theory, or the way in which the theory encourages subject specialists to discuss their area of interest in depth. This commentary critically examines how Threshold Concepts have been used and researched within health professions education, applying critiques from other educational fields, to assist scholars in thinking critically regarding their application.

EVIDENCE

Three significant critiques are outlined: 1) 'The floating signifier problem'; 2) 'The body of knowledge problem'; and 3) 'The professional identity problem.' Critique 1, the floating signifier problem, outlines how Threshold Concept theory lacks articulation and has been inconsistently operationalized. Critique 2, the body of knowledge problem, outlines the issues associated with attempting to identify a singular body of knowledge, particularly in regard to the reinforcement of entrenched power dynamics. Critique 3, the professional identity problem, argues that the way in which Threshold Concepts conceptualize identity formation is problematic, inadequately grounded in wider academic debate, and at odds with increasingly constructionist conceptualizations of identity within health professions education.

IMPLICATIONS

These critiques have implications for both educators and researchers. Educators using Threshold Concepts theory must think carefully about the tacit messages their use communicates, consider how the use of Threshold Concepts could reinforce entrenched power dynamics, and reflect on how their use may make material less accessible to some learners. Further, given that Threshold Concept theory lacks articulation, using the theory to structure curricula or educational sessions is problematic. Threshold Concepts are not synonymous with course learning outcomes and so, While considering Threshold Concepts may enable pedagogical discussion, the theory cannot help educators decide which concepts it applies to; this requires careful planning which extends beyond the bounds of this theory. For researchers, there are issues too with power and inconsistent theoretical operationalization, but also with the way in which Threshold Concepts theory conceptualizes identity formation, which cast doubt on its use as a theory of identity development. On balance, we believe Threshold Concept theory suffers a number of fundamental flaws that necessitate a shift from the positioning of Threshold Concepts as a theory, toward the use of Threshold Concepts as a less prescriptive reflective prompt to stimulate pedagogical discussion.

Tangrams: a simple visual tool for communicating the complexities of professionalism

Professionalism is vital for high quality healthcare and fundamental to health profession education. It is however complex, hard to define and can be challenging to teach, learn about and assess. We describe the development and use of an innovative visual tool, using a tangram analogy, to introduce and explore core professionalism concepts, which are often troublesome for both learners and educators. These include the hidden curriculum, capability, professional identity and the difference between unprofessionalism and high professional standards.  Understanding these concepts can help individuals to see professionalism differently, encourage faculty to design professionalism programmes which focus on professional excellence, support assessors to feel more confident in identifying and addressing underperformance and facilitate learners to appreciate the complexity and uncertainty inherent in professionalism and to become more alert to the hidden curriculum and its potential impact. We have used the tangram model to educate for professionalism in multiple contexts with learners and educators. Participants regularly report that it leads to a deeper understanding and important new insights around professionalism and helps them identify ways of changing their practice.  We believe this approach has relevance across the health professions and suggest ways it could be further developed to explore wider professionalism issues such as reflective practice, resilience and teamworking.

Toward 'seeing' critically: a Bayesian analysis of the impacts of a critical pedagogy

Critical reflection supports enactment of the social roles of care, like collaboration and advocacy. We require evidence that links critical teaching approaches to future critically reflective practice. We thus asked: does a theory-informed approach to teaching critical reflection influence what learners talk about (i.e. topics of discussion) and how they talk (i.e. whether they talk in critically reflective ways) during subsequent learning experiences? Pre-clinical students (n = 75) were randomized into control and intervention conditions (8 groups each, of up to 5 interprofessional students). Participants completed an online Social Determinants of Health (SDoH) module, followed by either: a SDoH discussion (control) or critically reflective dialogue (intervention). Participants then experienced a common learning session (homecare curriculum and debrief) as outcome assessment, and another similar session one-week later. Blinded coders coded transcripts for what (topics) was said and how (critically reflective or not). We constructed Bayesian regression models for the probability of meaning units (unique utterances) being coded as particular what codes and as critically reflective or not (how). Groups exposed to the intervention were more likely, in a subsequent learning experience, to talk in a critically reflective manner (how) (0.096 [0.04, 0.15]) about similar content (no meaningful differences in what was said). This difference waned at one-week follow up. We showed experimentally that a particular critical pedagogical approach can make learners' subsequent talk, ways of seeing, more critically reflective even when talking about similar topics. This study offers the field important new options for studying historically challenging-to-evaluate impacts and supports theoretical assertions about the potential of critical pedagogies.

Tangrams: a simple visual tool for communicating the complexities of professionalism

Professionalism is vital for high quality healthcare and fundamental to health profession education. It is however complex, hard to define and can be challenging to teach, learn about and assess. We describe the development and use of an innovative visual tool, using a tangram analogy, to introduce and explore core professionalism concepts, which are often troublesome for both learners and educators. These include the hidden curriculum, capability, professional identity and the difference between unprofessionalism and high professional standards.  Understanding these concepts can help individuals to see professionalism differently, encourage faculty to design professionalism programmes which focus on professional excellence, support assessors to feel more confident in identifying and addressing underperformance and facilitate learners to appreciate the complexity and uncertainty inherent in professionalism and to become more alert to the hidden curriculum and its potential impact. We have used the tangram model to educate for professionalism in multiple contexts with learners and educators. Participants regularly report that it leads to a deeper understanding and important new insights around professionalism and helps them identify ways of changing their practice.  We believe this approach has relevance across the health professions and suggest ways it could be further developed to explore wider professionalism issues such as reflective practice, resilience and teamworking.

The KAIROS Blanket Exercise: Engaging Indigenous ways of knowing to foster critical consciousness in medical education

PURPOSE

Indigenous Peoples across Turtle Island (North America) experience ongoing health disparities tied to the effects of colonization and persistent racism toward Indigenous Peoples. Educating future clinicians to develop a critical consciousness is an important way to work toward cultural safety and improve the health care experiences of Indigenous patients. The present study evaluated the ability of the KAIROS Blanket Exercise (KBE) to foster critical consciousness.

METHODS

Two hundred thirteen medical students at the University of Toronto participated in the KBE. Subsequently, 174 students completed a paper evaluation, designed to capture concepts of cultural safety and critical consciousness. Data were analyzed using quantitative and qualitative methods to identify shifts in perspectives.

RESULTS

The majority of students reported the exercise altered the way they viewed those from backgrounds different from their own, and comments regarding bias, power and privilege were highlighted throughout the responses. Engaging in critical reflection through dialogue and revealing the complex sociopolitical context of Indigenous Peoples' history were emphasized as central to this transformation.

CONCLUSIONS

Following participation in the KBE, medical students demonstrated a shift in their perspectives. This suggests that creating curricular space for critical pedagogy may be effective in fostering critical consciousness, ultimately encouraging reflexive practice and social action.

Contending with Our Racial Past in Medical Education: A Foucauldian Perspective

Practices of systemic and structural racism that advantage some groups over others are embedded in American society. Institutions of higher learning are increasingly being pressured to develop strategies that effectively address these inequities. This article examines medical education's diversity reforms and inclusion practices, arguing that many reify preexisting social hierarchies that privilege white individuals over those who are minoritized because of their race/ethnicity. Evidence: Drawing on the work of French theorist Michel Foucault, we argue that medical education's curricular and institutional practices reinforce asymmetrical power differences and authority in ways that disadvantage minoritized individuals. Practices, such as medical education's reliance on biomedical approaches, cultural competency, and standardized testing reinforce a racist system in ways congruent with the Foucauldian concept of "normalization." Through medical education's creation of subjects and its ability to normalize dominant forms of knowledge, trainees are shaped and socialized into ways of thinking, being, and acting that continue to support racial violence against minoritized groups. The systems, structures, and practices of medical education need to change to combat the pervasive forces that continue to shape racist institutional patterns. Individual medical educators will also need to employ critical approaches to their work and develop strategies that counteract institutional systems of racial violence. Implications: A Foucauldian approach that exposes the structural racism inherent in medical education enables both thoughtful criticism of status-quo diversity practices and practical, theory-driven solutions to address racial inequities. Using Foucault's work to interrogate questions of power, knowledge, and subjectivity can expand the horizon of racial justice reforms in medicine by attending to the specific, pervasive ways racial violence is performed, both intra- and extra-institutionally. Such an intervention promises to take seriously the importance of anti-racist methodology in medicine.

Southern exposure: levelling the Northern tilt in global medical and medical humanities education

Global medical education is dominated by a Northern tilt. Global universities' faculty and students dominate research, scholarship and teaching about what is termed global education. This tilt has been fixed in global biomedical education with some acknowledgement from the Global South of the comparative benefits of global exchange. Student exchange is predominantly North to South. Students from the Global South are less likely to visit the North on global medical education visits. Global indigenous and traditional ways of knowing rooted may be suppressed, hidden or misappropriated and repackaged for consumption in the Global South with Global North ways of knowing as a reference point. A global history of colonization has shaped this trend influencing postcolonial theorists and decolonial activists to question the legitimacy and depose the influence of dominant Global North ideas. This is evident in how communication skills, reflective practice and narratives are presented and taught. Global North students must be introduced to Global South ways of knowing before visiting the Global South from a position of critical consciousness. Emancipatory education is best led by transformative Global North-South dialogue.

Patient-Centered Medicine: A Necessary Condition for the Management of Functional Somatic Syndromes and Bodily Distress

This paper argues that “functional,” “medically unexplained,” or “somatoform” symptoms and disorders necessarily require a patient-centered approach from the clinicians. In the first part, I address the multiple causes of the patients' suffering and I analyze the unease of the doctors faced with these disorders. I emphasize the iatrogenic role of medical investigations and the frequent failure in attempting to reassure the patients. I stress the difficulties in finding the right terms and concepts, despite overabundant nosological categories, to give a full account of psychosomatic complexity. Finally, I discuss the moral dimension attached to assigning a symptom, at times arbitrarily, to a psychogenic origin. The following part presents a brief reminder of the patient-centered approach (PCA) in medicine. In the last part, I aim to explain why and how patient-centered medicine should be applied in the context of functional disorders. First, because PCA focuses on the patients' experience of illness rather than the disease from the medical point of view, which is, indeed, absent. Second, because PCA is the only way to avoid sterile attribution conflicts. Last, because PCA allows doctors and patients to collaboratively create plausible and non-stigmatizing explanations for the symptoms, which paves the way toward effective management.

Being Vulnerable: A Qualitative Inquiry of Physician Touch in Medical Education

PURPOSE

Effective nonverbal communication is associated with empathic behavior and improved patient outcomes. Touch, as a form of nonverbal communication, is relatively unexplored in medical education. This study sought to gain in-depth insights into physicians' experiences communicating with touch and to examine how these insights could inform communication skills curricula.

METHOD

Collaborative inquiry, a form of action research, was used. Six experienced physician-educators from the University of Calgary met 8 times between 2015 and 2018 to critically reflect on their experiences of touch in clinical practice, teaching, and learning. Data comprised meeting transcripts, individual narrative accounts, and digital recordings of role-plays. Interpretative phenomenology, the study of lived experience, guided analysis.

RESULTS

Two themes were identified-touch as presence and touch as risk. Participants used touch to demonstrate presence and a shared humanity with patients, to express "being with" a patient. Risk was not associated with the physical experience of touch but, rather, with its social meaning, interpreted through gender, culture, relationships, and context. Individual experiences were open to many interpretations. Participants expressed tension between their personal experience communicating with touch to express empathy and formal curricular structures. Reflection, role-modeling, and clinical debriefs were suggested as ways to encourage situational awareness and sensitive use of touch.

CONCLUSIONS

Touch is a powerful means to communicate with patients but is highly subjective. Rather than avoiding touch for fear of misinterpretation, encouraging dialogue about its complexity could promote a more balanced understanding of touch and its potential to convey empathy and help physicians more effectively manage risk when using touch.

"Starting from a higher place": linking Habermas to teaching and learning clinical reasoning in the emergency medicine context

Teaching clinical reasoning in emergency medicine requires educators to foster diagnostic accuracy and judicious decision-making amidst chaotic ambient factors including clinician fatigue, high cognitive load, and diverse patient expectations. The current study applies the early work of Jurgen Habermas and his knowledge-constitutive interests as a lens to explore an educational approach where physician-educators were asked to make their expert reasoning visible to emergency medicine trainees, to more deliberately make visible and accessible the context-specific thinking that emergency physicians routinely use. An action research methodology was used. The 'making thinking visible' teaching approach was introduced to five emergency medicine educators working in large public hospital emergency departments. Participants were asked to trial this teaching method and document its impact on student learning over two reporting cycles. Based on written reports of trialing the teaching approach, participants identified a need to change from: (1) introducing thinking structures to cultivating enquiry; and, (2) providing explanations based on cognitive thinking routines towards encouraging the learner to see the relevance of the clinical context. Educators described how they developed a more diagnostic and reflexive approach to learners, recognized the need to cultivate independent thinking, and valued the opportunity to reflect on their usual teaching. Teaching clinical reasoning using the 'making thinking visible' approach prompted educators to decrease the emphasis on providing technical information to assisting learners to understand the purposes and meanings behind clinical reasoning in emergency medicine. The knowledge-constitutive interests work of Jurgen Habermas was found to provide a robust framework supporting this emancipatory teaching approach.

Honoring Medicine's Social Contract: A Scoping Review of Critical Consciousness in Medical Education

PURPOSE

To explore how the construct of critical consciousness has been conceptualized within the medical education literature and identify the main elements of critical consciousness in medical education so as to inform educational strategies to foster socially conscious physicians.

METHOD

In March 2019, the authors conducted a literature search of 4 databases and Google Scholar, seeking articles discussing critical consciousness in medical education published any time after 1970. Three of the authors screened articles for eligibility. Two transcribed data using a data extraction form and identified preliminary emerging themes, which were then discussed by the whole research team to ensure agreement.

RESULTS

Of the initial 317 articles identified, 20 met study inclusion criteria. The publication of academic articles around critical consciousness in medical education has expanded substantially since 2017. Critical consciousness has been conceptualized in the medical education literature through 4 overlapping themes: (1) social awareness, (2) cultural awareness, (3) political awareness, and (4) awareness of educational dynamics.

CONCLUSIONS

Critical consciousness has been conceptualized in medical education as an intellectual construct to foster a reflexive awareness of professional power in health care, to unearth the values and biases legitimizing medicine as currently practiced, and to foster transformation and social accountability. Scholars highlighted its potential to improve sociocultural responsibility and to foster compassion in doctors. Adopting a critical pedagogy approach in medical education can help uphold its social accountability through an intrinsic orientation to action, but any enterprise working toward embedding critical pedagogy within curricula must acknowledge and challenge the current structure and culture of medical education itself.

Embodied aspects of learning to be a surgeon

Embodied learning is an educational concept that has been applied to various aspects of education, but only touched on in medical education, largely in relation to the teaching and learning of anatomy. Thus far, the medical literature has not addressed embodied learning as it specifically relates to learning to operate and be a surgeon. This paper will discuss relevant principles of embodied learning/cognition, ways it is important both for learning to function as a surgeon and for learning to perform technical aspects of surgery, and finally will discuss implications for surgical education. In particular, it will address ways in which embodied learning can and should be incorporated into educational activities specific to surgery.

Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment

OBJECTIVE

Co-production involves service providers and service users collaborating to design and deliver services together and is gaining attention as a means to improve provision of care. Aiming to extend this model to an educational context, the authors assembled a diverse group to develop co-produced education for psychiatry residents and medical students at the University of Toronto over several years. The authors describe the dynamics involved in co-producing psychiatric education as experienced in their work.

METHODS

A collaborative autobiographical case study approach provides a snapshot of the collective experiences of working to write a manuscript about paying service users for their contributions to co-produced education. Data were collected from two in-person meetings, personal communications, emails, and online comments to capture the fullest possible range of perspectives from the group about payment.

RESULTS

The juxtaposition of the vision for an inclusive process against the budgetary constraints that the authors faced led them to reflect deeply on the many meanings of paying service user educators for their contributions to academic initiatives. These reflections revealed that payment had implications at personal, organizational, and social levels.

CONCLUSION

Paying mental health service user educators for their contributions is an ethical imperative for the authors. However, unless payment is accompanied by other forms of demonstrating respect, it aligns with organizational structures and practices, and it is connected to a larger goal of achieving social justice, the role of service users as legitimate knowers and educators and ultimately their impact on learners will be limited.

Critically reflective practice and its sources: A qualitative exploration

CONTEXT

Critical reflection may improve health professionals' performance of the social roles of care (eg collaboration) in indeterminate zones of practice that are ambiguous, unique, unstable or value-conflicted. Research must explore critical reflection in practice and how it is developed. In this study, we explored what critical reflection consisted of in a context known for indeterminacy, and to what sources participants attributed their critically reflective insights and approaches.

METHODS

The study context was the interface between health care and education for children with chronic conditions or disabilities necessitating health-related recommendations and supports (eg accommodations or equipment) at school. We conducted a secondary analysis of 42 interview transcripts from an institutional ethnographic study involving health professionals, school-based educators and parents of children with chronic conditions or disabilities. We coded all transcripts for instances of critical reflection, moments that seemed to lack but could benefit from critical reflection, and participant-attributed sources of critically reflective insights.

RESULTS

Critically reflective practice involved getting to know the other, valuing and leveraging different forms and sources of knowledge, identifying and communicating workarounds (ie strategies to circumvent imperfect systems), seeing inequities, and advocating as collaborators, not adversaries. Participants invariably attributed critically reflective insights to personal experiences such as former careers or close personal relationships.

CONCLUSIONS

This study shows that personal experiences and connections inspire critically reflective views, and that being critically reflective is not a binary trait possessed (or not) by individuals. It is learnable through personally meaningful experiences. Health professions education could aim to preserve philosophical space for personal experience as a source of learning and integrate evidence-informed approaches to foster critically reflective practice.

Broadening Medical Students' Exposure to the Range of Illness Experiences: A Pilot Curriculum Focused on Depression Education

PROBLEM

Exposing medical students to a broad range of illness experiences is crucial for teaching them to practice patient-centered care, but students often have limited interaction with patients with diverse illness presentations.

APPROACH

The authors developed, implemented, and evaluated a self-directed online curriculum followed by a small-group discussion focused on depression education. The curriculum was based on a module created using the Database of Individual Patients' Experiences methodology. Findings from 40 interviews with young adults across the United States about their diverse experiences with depression were summarized online, and the summaries were illustrated by video, audio, and text clips. From August 2016 to April 2017, third-year students completed either this online curriculum and the usual clerkship curriculum or just the usual clerkship curriculum. These intervention and control groups completed pre- and postsurveys.

OUTCOMES

Students in the intervention group reported that the online curriculum influenced their thinking about depression (51/56) nearly as often as they reported that seeing patients in clinic did (53/56). They also reported greater decreases in personal stigmatizing attitudes toward depression than did students in the control group as measured by the Depression Stigma Scale (5.75-4.02, intervention; 6.50-5.65, control; P = .004). In open-ended responses, students in the intervention group were 13 times more likely to describe key lessons from the curriculum that reflected patient heterogeneity.

NEXT STEPS

Future collaborations include implementing and evaluating this curriculum at other medical schools and developing additional versions based on other illness experiences.

'There shouldn't be anything wrong with not knowing': epistemologies in simulation

CONTEXT

Medical education embraces simulation-based education (SBE). However, key SBE features purported to support learning, such as learner safety and learning through experience and error, may not align with the dominant culture of medicine, in which portraying confidence and certainty about one's knowledge prevails. Misaligned conceptions about knowledge and learning may produce unintended negative effects, including the suboptimal implementation of SBE, which could consequently compromise SBE and its outcomes.

METHODS

To uncover the epistemological beliefs of students experiencing SBE, we conducted a theory-informed analysis of interviews with 24 pre-clerkship medical students following their participation in an SBE training study. Our analysis borrowed from coding methods common in constructivist grounded theory and used Hofer and Pintrich's four dimensions of epistemology as sensitising concepts.

RESULTS

Participants subscribed to a dominant view of knowledge as consisting of concrete facts, derived from external sources. By contrast, they described but did not prioritise a conception of building their own knowledge through different learning experiences. Participants positioned experts (i.e. teaching faculty members) as the ultimate knowledge validators through their presence and feedback. Participants also noted that faculty staff could counter medicine's pressures to perform with certainty and confidence at all times by instead embodying and modelling an authentic appreciation of learning through experiences, errors and discovery.

CONCLUSIONS

Medicine's tendency to idealise the objective pursuit of singular truths may compromise the purported culture of SBE as a space for learning many wide-ranging aspects of medicine, including how and when to innovate and deviate from norms. Explicit attempts to bridge the epistemological beliefs of medicine and SBE may better enable the realisation of safe experiential learning. Faculty members are positioned to play key roles in enabling this bridging.

Conceptualizing Medical Humanities Programs in Low-Resource Settings in Africa

The role of the humanities in medical education remains a topic of dynamic debate in medical schools of high-income countries. However, in most low- and middle-income countries, the medical humanities are less topical and rarely even have a place in the curriculum. Reasons for this dearth include inadequate resources to support such programs coupled with misapprehension of the role and significance of the humanities in medical education.In this article, the authors argue that the humanities have a vital role to play in the low-resource settings of African medical education. They discuss the complexities of the continent's sociohistorical legacies, in particular the impact of colonization, to provide contexts for conceptualizing humanities programs in African schools. They outline the challenges to developing and implementing such programs in the continent's underresourced medical schools and present these as four specific conundrums to be addressed. As a general guide, the authors then suggest four nonprescriptive content domains that African medical schools might consider in establishing medical humanities programs.The goal is to jump-start a crucial and timely discussion that will open the way for the feasible implementation of contextually congruent humanities programs in the continent's medical schools, leading to the enhanced education, training, and professional development of its graduating physicians.

The Divergence and Convergence of Critical Reflection and Critical Reflexivity: Implications for Health Professions Education

As a field, health professions education (HPE) has begun to answer calls to draw on social sciences and humanities (SS&H) knowledge and approaches for curricular content, design, and pedagogy. Two commonly used SS&H concepts in HPE are critical reflection and critical reflexivity. But these are often conflated, misunderstood, and misapplied. Improved clarity of these concepts may positively affect both the education and practice of health professionals. Thus, the authors seek to clarify the origins of each, identify the similarities and differences between them, and delineate the types of teaching and assessment methods that fit with critical reflection and/or critical reflexivity. Common to both concepts is an ultimate goal of social improvement. Key differences include the material emphasis of critical reflection and the discursive emphasis of critical reflexivity. These similarities and differences result in some different and some similar teaching and assessment approaches, which are highlighted through examples. The authors stress that all scientific and social scientific concepts and methods imported into HPE must be subject to continued scrutiny both from within their originating disciplines and in HPE. This continued questioning is core to the ongoing development of the HPE field and also to health professionals' thinking and practice.

Interprofessional practice: beyond competence

Interprofessional practice is commonly discussed in the literature in terms of competencies. In this study we move away from the theoretical notions of criteria, concepts and guidelines to adopt an ontological approach which seeks to stay as close to the lived experience as possible. Our research asked 12 participants from a variety of health disciplines to tell their stories of working interprofessionally. We sought to glean meaning from the lived experience. Our phenomenological hermeneutic approach and interpretation were informed by Heidegger and Gadamer. Rather than offering a thematic overview, in this article we share three stories from the research that were congruent with other stories. The first, told by a doctor, is of a resuscitation in an emergency department. It shows how the effective working together of the interprofessional team was more than each member following a resuscitation protocol. There was 'something' about how they worked together that made this story stand out, even though the patient died. The second story showcases how 'who' the person is makes a difference. This nurse makes an effort to get to know other staff as people, to find common interests. In such a way interprofessional practice comes to flourish. The third story shows how a physiotherapist and a psychologist joined in conversation to seek innovative possibilities for a challenging situation. In such a way each built on the others expertise and were excited at the success they achieved for the patient. From these ontological accounts we have come to see that interprofessional practice flourishes when practitioners are their authentic, caring selves. Who the person is matters.

Social justice and the medical librarian

This lecture discusses social justice and the role that medical librarians can play in a democratic society. Social justice needs to be central to the mission of medical librarianship and a core value of the profession. Medical librarians must develop a new professional orientation: one that focuses on cultural awareness or cultural consciousness that goes beyond ourselves and our collections to that which focuses on the users of our libraries. We must develop a commitment to addressing the issues of societal, relevant health information. Using examples from medical education, this lecture makes the case for social justice librarianship. This lecture also presents a pathway for social justice medical librarianship, identifies fundamental roles and activities in these areas, and offers strategies for individual librarians, the Medical Library Association, and library schools for developing social justice education and outcomes. The lecture advocates for an understanding of and connection to social justice responsibilities for the medical library profession and ends with a call to go beyond understanding to action.

The lecture emphasizes the lack of diversity in our profession and the importance of diversity and inclusion for achieving social justice. The lecture presents specific examples from some medical libraries to extend the social justice mindset and to direct outreach, collections, archives, and special collection services to expose previously hidden voices. If medical librarians are to remain relevant in the future, we must act to address the lack of diversity in our profession and use our information resources, spaces, and expertise to solve the relevant societal issues of today.

Three visions of doctoring: a Gadamerian dialogue

Medicine in the twenty-first century faces an 'identity crisis,' as it grapples with the emergence of various 'ways of knowing,' from evidence-based and translational medicine, to narrative-based and personalized medicine. While each of these approaches has uniquely contributed to the advancement of patient care, this pluralism is not without tension. Evidence-based medicine is not necessary individualized; personalized medicine may be individualized but is not necessarily person-centered. As novel technologies and big data continue to proliferate today, the focus of medical practice is shifting away from the dialogic encounter between doctor and patient, threatening the loss of humanism that many view as integral to medicine's identity. As medical trainees, we struggle to synthesize medicine's diverse and evolving 'ways of knowing' and to create a vision of doctoring that integrates new forms of medical knowledge into the provision of person-centered care. In search of answers, we turned to twentieth-century philosopher Hans-Georg Gadamer, whose unique outlook on "health" and "healing," we believe, offers a way forward in navigating medicine's 'messy pluralism.' Drawing inspiration from Gadamer's emphasis on dialogue and 'practical wisdom' (phronesis), we initiated a dialogue with the dean of our medical school to address the question of how medical trainees and practicing clinicians alike can work to create a more harmonious pluralism in medicine today. We propose that implementing a pluralistic approach ultimately entails 'bridging' the current divide between scientific theory and the practical art of healing, and involves an iterative and dialogic process of asking questions and seeking answers.

Persistent influence of a narrative educational program on physician attitudes regarding patient care

PURPOSE

Educational approaches involving patient stories aim at enhancing empathy and patient-centered care; however, it is not known whether the influence of such programs on physician attitudes persists beyond medical school.

MATERIALS AND METHODS

The Family Centered Experience (FCE) paired preclinical medical students with patient families over two years and engaged students in reflective dialogs about the volunteers' stories. This study examined possible long-term influences on attitudes toward medicine and doctoring. Interviews were conducted with former students at the end of or after post-graduate training. All had completed the FCE between 4 and 10 years before the study. Thematic analysis was informed by a constructivist Grounded Theory approach.

RESULTS

Several themes were identified. The FCE made graduates aware of the patients' perspectives and impacted their clinical practice in specific ways, such as developing collaborative partnerships, conducting family meetings, and breaking bad news. The course had influenced career choices and interest in teaching. Finally, the FCE enhanced appreciation of the human dimensions of medicine, which graduates had drawn upon in subsequent years.

CONCLUSIONS

A program based on longitudinal interactions with individuals with chronic illness can have persistent influence by stimulating reflection on the patient's perspective and humanistic approaches to patient care.

Eliciting tacit knowledge: The potential of a reflective approach to video-stimulated interviewing

None

'Fostering transformative learning, self-reflexivity and medical citizenship through guided tours of disadvantaged neighborhoods'

BACKGROUND AND OBJECTIVES

Medical school curricula increasingly seek to promote medical students' commitment to redressing health disparities, but traditional pedagogical approaches have fallen short of this goal. The objective of this work was to assess the value of using community-based guided tours of disadvantaged neighborhoods to fill this gap.

METHODS

A total of 50 second-year medical students participated in a guided tour of disadvantaged public housing neighborhoods in Richmond, Virginia. Students completed self-reflexive writing exercises during a post-tour debriefing session. Student writings were analyzed to assess the tour's effect on their awareness of poverty's impact on vulnerable populations' health and wellbeing, and their personal reactions to the tour.

RESULTS

Student writings indicated that the activity fostered transformative learning experiences around the issue of poverty and its effects on health and stimulated a personal commitment to working with underserved populations. Themes from qualitative analysis included: increased awareness of the extent of poverty, enhanced self-reflexive attitude towards personal feelings, biases and misperceptions concerning the poor, increased intentional awareness of the effects of poverty on patient health and well-being, and, encouragement to pursue careers of medical service.

CONCLUSIONS

This pilot demonstrated that incorporating self-reflexive learning exercises into a brief community-based guided tour can enhance the social consciousness of medical students by deepening understandings of health disparities and promoting transformative learning experiences.

Dialogues on the Threshold: Dialogical Learning for Humanism and Justice

Given the constant pressures of overflowing clinics, hospital wards, and emergency departments; shortened duty hours; and increased accreditation requirements, overburdened clinician teachers ask, "How does one teach for humanism and justice?" How does one step away-even momentarily-and focus teaching on the individual in front of us, the person who requires our attention and care? This approach must not only involve content (the patient's perspective of illness, social context, and life story) but also must be tightly linked with the ways in which these lessons in living are learned and taught. In this article, the authors propose recognition and use of a style of communication that is already implicitly present in clinical conversations and that is uniquely capable of stimulating reflection on the human dimensions of medicine: that of dialogue.Dialogue involves committing one's whole self to communicative exchange and emphasizes interpersonal relationships and trust. Its result is often not a specific answer; rather, it is enhanced understanding through the generation of new questions and possibilities and action in implementing solutions. It requires a reorientation of the teacher-learner relationship from top-down to one of open exchange and shared authority and responsibility. In the context of professional identity development, these conversations become dialogues on the threshold of transformative change. Through an exploration of dialogical teaching, the authors envision clinical education as constantly stepping in and out of goal-oriented discussions and reflective dialogues, all with the overall goal to educate physicians who practice with excellence, compassion, and justice.

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.

Getting the picture: visual interpretation in ophthalmology residency training

OBJECTIVES

Visual interpretation is essential in many fields of health care. Although diagnostic competency can be measured as an educational outcome, few accounts have addressed tacit aspects of visual interpretation in clinical training; these include the disciplining of the trainee's attentions and the trainee's acculturation into expected styles of communicating visual interpretations to others. This paper describes values and dispositions that are taught to ophthalmology trainees as they learn to reason through visual information, and explores how these qualities are evaluated during residency training.

METHODS

The project was based on 6 months of ethnographic participant observation and interviews in an ophthalmology residency programme. Observational notes and interview transcripts pertaining to visual interpretation were isolated for qualitative analysis in the tradition of sociocultural anthropology, guided by literature on communication in medical education and the socialisation of health professionals.

RESULTS

Residents and faculty members identified visual interpretation as one of the most challenging skills expected of ophthalmology trainees. They expressed a belief that 'systematic' approaches, where visual information is parsed in a stepwise fashion, reduce the chance of trainees overlooking or misinterpreting key diagnostic features. This sensory discipline was represented in narrative form when faculty members asked residents to interpret images aloud, as residents were expected to follow prescribed sequences for describing the content of images before commenting on possible diagnoses.

CONCLUSIONS

Sensory processing is ordinarily opaque to outside observers, but the ritual of describing images in highly regimented narratives allows residents to demonstrate how they gather and reason through visual information. The form of these narratives reflects values that residents are expected to embody during their training, such as being thorough and methodical; it may also serve a pedagogical function by entrenching those values. Further research is needed to characterise how the performance of speech genres shapes the interpretive skills of medical trainees.

Looking Back to Move Forward: First-Year Medical Students' Meta-Reflections on Their Narrative Portfolio Writings

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students' reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster "reflective spaces" wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University Vagelos College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students' "Signature Reflections," end-of-semester meta-reflections on their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students' writings and interpret the data. The authors identified two overarching interpretive themes-recognition and grappling-and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors' analyses, the Signature Reflection seems to provide a structured framework that encourages students' reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students' acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.

The development of a competency model and its implementation in a power utility cooperative: an action research study

Purpose

The purpose of this paper is to trace the development of a competency model in a medium-scale power utility company located in the Midwest USA.

Design/methodology/approach

The model is developed based on insights drawn from the literature, company documents, and primary interviews with the key company stakeholders. The research process was carried out according to the guidelines of action research methodology.

Findings

Competencies required for employees were identified and operationally defined. Existing competencies were inventoried and superimposed on the required competencies. Gaps in competency presence and proficiency levels were noticed. The competencies required for effective performance were distributed across different levels in the hierarchy, according to the competency needs of each hierarchical level.

Practical implications

Attempts to tie these competencies to employee selection, succession planning, performance appraisal, training need assessment, leadership development, etc., are currently ongoing. The case company has also initiated a competency-driven leadership development process. Possible adaptations of this model for similarly placed companies in other sectors are discussed.

Originality/value

This is an original case study based on primary data, conducted as action research.

Exploration of Global Health Careers Across the Medical Fields

BACKGROUND

Despite expansion of interest among American medical students in global health (GH), academic medical centers face multiple obstacles to the development of structured GH curricula and career guidance. To meet these demands we sought to provide a systematic analysis of the accounts of GH experts.

METHODS

We developed a collaborative, interview-based, qualitative analysis of GH experiences across six career-related themes that are relevant to medical students interested in GH: justification, medical education, economics, research prospects, law and ethics, and work-life balance. Seven GH faculty members were interviewed for 30-90 minutes using sample questions as guidelines. We applied a grounded theory approach to analyze the interview transcripts to discover an emerging theory pertinent to GH trainees.

FINDINGS

Regarding justification, 4 respondents defined GH as work with the underserved irrespective of geographic location; 5 respondents found sustainability imperative; and all respondents believe GH creates better physicians. Respondents identified many physician competencies developed through GH medical education, with 5 respondents agreeing that work with underserved populations has transformative potential. Concerning economics, 3 respondents acknowledged GH's popularity among trainees, resulting in increased training opportunities, and 2 respondents emphasized an associated deficiency in program quality. All respondents described career models across specialties. Four respondents noted funding challenges when discussing research prospects. Within the theme of laws and ethics, 4 respondents perceived inadequate accountability, and 6 respondents identified ways to create accountability. Finally, 6 respondents recognized family demands can compromise one's GH career and thus work-life balance.

CONCLUSION

Despite diverse perspectives on the meaning and sustainability of GH work, this analysis provides a nascent framework that may inform curricular development for GH trainees. Suggestions are offered for elaborating this framework to fully exploit the transformative potential of GH training in medical education.

Re-positioning faculty development as knowledge mobilization for health professions education

Faculty development as knowledge mobilization offers a particularly fruitful and novel avenue for exploring the research-practice interface in health professions education. We use this 'eye opener' to build off this assertion to envision faculty development as an enterprise that provides a formal, recognized space for the sharing of research and practical knowledge among health professions educators. Faculty development's knowledge mobilizing strategies and outcomes, which draw upon varied sources of knowledge, make it a potentially effective knowledge mobilization vehicle.First, we explain our choice of the term knowledge mobilization over translation, in an attempt to resist the false dichotomy of 'knowledge user' and 'knowledge creator'. Second, we leverage the documented strengths of faculty development against the documented critiques of knowledge mobilization in the hopes of avoiding some of the pitfalls that have befallen previous attempts at closing knowing-doing gaps.Through faculty development, faculty are indeed educated, in the traditional sense, to acquire new knowledge and skill, but they are also socialized to go on to form the systems and structures of their workplaces, as leaders and workers. Therefore, faculty development can not only mobilize knowledge, but also create knowledge mobilizers. Achieving this vision of faculty development as knowledge mobilization requires an acceptance of multiple sources of knowledge, including practice-based knowledge, and of multiple purposes for education and faculty development, including professional socialization.

Integrating Theory, Content, and Method to Foster Critical Consciousness in Medical Students: A Comprehensive Model for Cultural Competence Training

Many efforts to design introductory "cultural competence" courses for medical students rely on an information delivery (competence) paradigm, which can exoticize patients while obscuring social context, medical culture, and power structures. Other approaches foster a general open-minded orientation, which can remain nebulous without clear grounding principles. Medical educators are increasingly recognizing the limitations of both approaches and calling for strategies that reenvision cultural competence training. Successfully realizing such alternative strategies requires the development of comprehensive models that specify and integrate theoretical frameworks, content, and teaching principles.In this article, the authors present one such model: Introduction to Medicine and Society (IMS), a required cultural competence course launched in 2013 for first-year medical students at the Perelman School of Medicine at the University of Pennsylvania. Building on critical pedagogy, IMS is centered on a novel specification of "critical consciousness" in clinical practice as an orientation to understanding and pragmatic action in three relational domains: internal, interpersonal, and structural. Instead of transmitting discrete "facts" about patient "types," IMS content provokes students to engage with complex questions bridging the three domains. Learning takes place in a small-group space specifically designed to spur transformation toward critical consciousness. After discussing the three key components of the course design and describing a representative session, the authors discuss the IMS model's implications, reception by students and faculty, and potential for expansion. Their early experience suggests the IMS model successfully engages students and prepares future physicians to critically examine experiences, manage interpersonal dynamics, and structurally contextualize patient encounters.