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Gülpınar MA, Tanrıöver Ö. Integration of behavioral, social, and humanities sciences into healthcare and education and their alignment with medical education programs. MEDICAL TEACHER 2024:1-11. [PMID: 39087366 DOI: 10.1080/0142159x.2024.2377384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/03/2024] [Indexed: 08/02/2024]
Abstract
There has been an increasing acknowledgment of the intricacies inherent in health and healthcare processes, leading to a shift in medical education. This change underscores multidimensional, thorough, reflective, and contextual approaches characterized by mutual interaction and change. The perception of health/well-being and illness is transitioning toward acknowledging them as outcomes arising from the complex interplay of individual, social, and environmental/ecosystemic factors. This includes biological, genetic, behavioral, sociocultural, and environmental influences. In line with this changing perspective, the purpose of this article is to provide a general framework for the integration of behavioral, social, and human sciences into Medical Education Programs in Healthcare and Training Processes. The framework presented is based on the following three conceptual and theoretical basis: (1) Complex systems thinking and reflective, contextual healthcare and education practices, (2) Health systems and socio-economic-political framework, (3) Ecosystem framework in health and disease. Our aim in this article is to provide a guide for the integration of Behavioral, Social, and Humanity Sciences into medical education programs and to present examples from around the world.
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Affiliation(s)
- Mehmet Ali Gülpınar
- Department of Medical Education, Marmara University School of Medicine, Istanbul, Turkey
| | - Özlem Tanrıöver
- Department of Medical Education, Marmara University School of Medicine, Istanbul, Turkey
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Krimmel-Morrison JD, Watsjold BK, Berger GN, Bowen JL, Ilgen JS. 'Walking together': How relationships shape physicians' clinical reasoning. MEDICAL EDUCATION 2024; 58:961-969. [PMID: 38525645 DOI: 10.1111/medu.15377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning. METHODS Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest. RESULTS The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts. CONCLUSION Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.
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Affiliation(s)
| | - Bjorn K Watsjold
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Gabrielle N Berger
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Judith L Bowen
- Department of Medical Education and Clinical Sciences, Washington State University Elson S. Floyd School of Medicine, Spokane, Washington, USA
| | - Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Clinical sensemaking: Advancing a conceptual learning model of clinical reasoning. MEDICAL EDUCATION 2024. [PMID: 38899766 DOI: 10.1111/medu.15461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 05/06/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
CONTEXT Much remains unanswered regarding how clinical reasoning is learned in the clinical environment. This study attempts to unravel how novice medical students learn to reason, by examining how they make sense of the clinical patient encounter. METHOD The current study was part of a greater research project employing constructivist grounded theory (CGT) to develop a learning model of clinical reasoning. Introducing the sensemaking perspective, as a sensitising concept, we conducted a second level analytic phase with CGT, to further advance our previously developed model. This involved re-examining collected data from semi-structured interviews, participant observations and field interviews of novice students during their early clinical clerkships. RESULTS A learning model of how medical students make sense of the patient encounter emerged from the analysis. At its core lie three interdependent processes that co-constitute the students' clinical sensemaking activity. Framing the situation is the process whereby students discern salient situational elements, place them into a meaningful relationship and integrate them into a clinical problem. Inquiring into the situation is the process whereby students gain further insight into the situation by determining which questions need to be asked. Lastly, taking meaningful action is the process whereby students carve out a pathway of action, appropriate for the circumstances. Tensions experienced during these processes impair clinical sensemaking. CONCLUSIONS The study provides an empirically informed learning model of clinical reasoning, during the early curricular stages. The model attempts to capture the complexity of medical practice, as students learn to recognise and respond to what constitutes the essence of a clinical situation. In this way, it contributes to a conceptual shift in how we think and talk about clinical reasoning. It introduces the concept of clinical sensemaking, as the act of carving a tangible clinical problem out of an often undetermined clinical situation and pursuing justified action.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Department of Infectious Diseases, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Durning SJ, Jung E, Kim DH, Lee YM. Teaching clinical reasoning: principles from the literature to help improve instruction from the classroom to the bedside. KOREAN JOURNAL OF MEDICAL EDUCATION 2024; 36:145-155. [PMID: 38835308 DOI: 10.3946/kjme.2024.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/30/2024] [Indexed: 06/06/2024]
Abstract
Clinical reasoning has been characterized as being an essential aspect of being a physician. Despite this, clinical reasoning has a variety of definitions and medical error, which is often attributed to clinical reasoning, has been reported to be a leading cause of death in the United States and abroad. Further, instructors struggle with teaching this essential ability which often does not play a significant role in the curriculum. In this article, we begin with defining clinical reasoning and then discuss four principles from the literature as well as a variety of techniques for teaching these principles to help ground an instructors' understanding in clinical reasoning. We also tackle contemporary challenges in teaching clinical reasoning such as the integration of artificial intelligence and strategies to help with transitions in instruction (e.g., from the classroom to the clinic or from medical school to residency/registrar training) and suggest next steps for research and innovation in clinical reasoning.
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Affiliation(s)
- Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, MD, USA
| | - Eulho Jung
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, MD, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Do-Hwan Kim
- Department of Medical Education, Hanyang University College of Medicine, Seoul, Korea
| | - Young-Mee Lee
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
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Benbassat J. Trust in public health policy in the time of the COVID-19 epidemic in Israel. Isr J Health Policy Res 2024; 13:24. [PMID: 38664713 PMCID: PMC11044392 DOI: 10.1186/s13584-024-00607-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
The government of Israel provides universal health care through four health care organizations ("sick funds") that enjoy general public trust. In hindsight, the response of the government to the COVID-19 epidemic seems reasonable. In the first year of the epidemic, tests and vaccines were developed and other measures were taken, including social distancing, focusing on risk factors for infection and disease severity, and improving treatment. The COVID-19 mortality rate between January 2000 and June 2021 was around 750 per million inhabitants, well below the OECD average of 1300. Still, although the control measures were largely well received, the media and an ad hoc non-governmental Emergency Council for the coronavirus crisis in Israel criticized the government's response to the epidemic thereby contributing to a decline in public trust in government policy. This commentary provides an overview of the importance of trust in medical institutions and the difficulties of evaluating healthcare decisions in an attempt to justify three conclusions. First, when physicians and self-appointed experts publicly disapprove of a government policy, they should consider the trade-off between improving care and undermining public trust. Second, when evaluating a medical decision, experts should not ask, "Would I have acted differently?" but rather, "Was the decision under review completely unreasonable?" Thirdly, criticism is certainly worth listening to. However, I believe that by calling for organized resistance against the government, the publicly announced establishment of the Emergency Council for the Corona crisis blatantly crossed the line between constructive criticism and destructive mistrust.
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Affiliation(s)
- Jochanan Benbassat
- Department of Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel.
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Penner JC, Schuwirth L, Durning SJ. From Noise to Music: Reframing the Role of Context in Clinical Reasoning. J Gen Intern Med 2024; 39:851-857. [PMID: 38243110 PMCID: PMC11043232 DOI: 10.1007/s11606-024-08612-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024]
Affiliation(s)
- John C Penner
- Department of Medicine, University of California, San Francisco, CA, USA.
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Lambert Schuwirth
- Prideaux Discipline of Clinical Education, Flinders University, Adelaide, SA, Australia
| | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Ten Cate O, Khursigara-Slattery N, Cruess RL, Hamstra SJ, Steinert Y, Sternszus R. Medical competence as a multilayered construct. MEDICAL EDUCATION 2024; 58:93-104. [PMID: 37455291 DOI: 10.1111/medu.15162] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/31/2023] [Accepted: 06/15/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The conceptualisation of medical competence is central to its use in competency-based medical education. Calls for 'fixed standards' with 'flexible pathways', recommended in recent reports, require competence to be well defined. Making competence explicit and measurable has, however, been difficult, in part due to a tension between the need for standardisation and the acknowledgment that medical professionals must also be valued as unique individuals. To address these conflicting demands, a multilayered conceptualisation of competence is proposed, with implications for the definition of standards and approaches to assessment. THE MODEL Three layers are elaborated. This first is a core layer of canonical knowledge and skill, 'that, which every professional should possess', independent of the context of practice. The second layer is context-dependent knowledge, skill, and attitude, visible through practice in health care. The third layer of personalised competence includes personal skills, interests, habits and convictions, integrated with one's personality. This layer, discussed with reference to Vygotsky's concept of Perezhivanie, cognitive load theory, self-determination theory and Maslow's 'self-actualisation', may be regarded as the art of medicine. We propose that fully matured professional competence requires all three layers, but that the assessment of each layer is different. IMPLICATIONS The assessment of canonical knowledge and skills (Layer 1) can be approached with classical psychometric conditions, that is, similar tests, circumstances and criteria for all. Context-dependent medical competence (Layer 2) must be assessed differently, because conditions of assessment across candidates cannot be standardised. Here, multiple sources of information must be merged and intersubjective expert agreement should ground decisions about progression and level of clinical autonomy of trainees. Competence as the art of medicine (Layer 3) cannot be standardised and should not be assessed with the purpose of permission to practice. The pursuit of personal excellence in this level, however, can be recognised and rewarded.
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Affiliation(s)
- Olle Ten Cate
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Richard L Cruess
- Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada
| | - Stanley J Hamstra
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Yvonne Steinert
- Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada
| | - Robert Sternszus
- Department of Pediatrics, Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada
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Clarke SO, Ilgen JS, Regehr G. Fostering Adaptive Expertise Through Simulation. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:994-1001. [PMID: 37094295 DOI: 10.1097/acm.0000000000005257] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Technology-enhanced simulation has been used to tackle myriad challenges within health professions education. Recently, work has typically adopted a mastery learning orientation that emphasizes trainees' sequential mastery of increasingly complex material. Doing so has privileged a focus on performance and task completion, as captured by trainees' observable behaviors and actions. Designing simulation in these ways has provided important advances to education, clinical care, and patient safety, yet also placed constraints around how simulation-based activities were enacted and learning outcomes were measured. In tracing the contemporary manifestations of simulation in health professions education, this article highlights several unintended consequences of this performance orientation and draws from principles of adaptive expertise to suggest new directions. Instructional approaches grounded in adaptive expertise in other contexts suggest that uncertainty, struggle, invention, and even failure help learners to develop deeper conceptual understanding and learn innovative approaches to novel problems. Adaptive expertise provides a new lens for simulation designers to think intentionally around how idiosyncrasy, individuality, and inventiveness could be enacted as central design principles, providing learners with opportunities to practice and receive feedback around the kinds of complex problems they are likely to encounter in practice. Fostering the growth of adaptive expertise through simulation will require a fundamental reimagining of the design of simulation scenarios, embracing the power of uncertainty and ill-defined problem spaces, and focusing on the structure and pedagogical stance of debriefing. Such an approach may reveal untapped potential within health care simulation.
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Affiliation(s)
- Samuel O Clarke
- S.O. Clarke is associate professor, Department of Emergency Medicine, University of California, Davis, Sacramento, California; ORCID: https://orcid.org/my-orcid?orcid=0000-0003-3762-1727
| | - Jonathan S Ilgen
- J.S. Ilgen is professor, Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4590-6570
| | - Glenn Regehr
- G. Regehr is professor, Department of Surgery, and senior scientist, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada; ORCID: https://orcid.org/0000-0002-3144-331X
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Ilgen JS, Watsjold BK, Regehr G. Is uncertainty tolerance an epiphenomenon? MEDICAL EDUCATION 2022; 56:1150-1152. [PMID: 36124815 DOI: 10.1111/medu.14938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Bjorn K Watsjold
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Glenn Regehr
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada
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Wyatt TR, Ho MJ, Teherani A. Centering Criticality in Medical Education Research: A Synthesis of the 2022 RIME Papers. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:S11-S14. [PMID: 35947467 DOI: 10.1097/acm.0000000000004903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Tasha R Wyatt
- T.R. Wyatt is associate director/associate professor, Uniformed Services University of the Health Sciences, Center for Health Professions Education, Bethesda, Maryland; ORCID: https://orcid.org/0000-0002-0071-5298
| | - Ming-Jung Ho
- M.-J. Ho is professor of family medicine and associate director, Center for Innovation and Leadership in Education (CENTILE), Georgetown University Medicine Center, and director of education research, MedStar Health, Washington, DC; ORCID: https://orcid.org/0000-0003-1415-8282
| | - Arianne Teherani
- A. Teherani is professor of medicine, director of program evaluation and continuous quality improvement, an education scientist, Center for Faculty Educators, and founding codirector, University of California Center for Climate, Health and Equity, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0003-2936-983
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