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Kim DT, Applewhite MK, Shelton W. Professional Identity Formation in Medical Education: Some Virtue-Based Insights. TEACHING AND LEARNING IN MEDICINE 2024; 36:399-409. [PMID: 37140086 DOI: 10.1080/10401334.2023.2209067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 04/12/2023] [Indexed: 05/05/2023]
Abstract
Issue: In 2010, the Carnegie Foundation published a call to reorient medical education in terms of the formation of identities rather than mere competencies, and the medical education literature on professional identity formation (PIF) has since grown rapidly. As medical learners navigate a hectic clinical learning environment fraught with challenges to professionalism and ethics, they must simultaneously orient their skills, behaviors, and evolving sense of professional identity. The medical education literature on PIF describes the psychosocial dimensions of that identity formation well. However, in its conceptual formulations, the literature risks underappreciating the pedagogical significance of the moral basis of identity formation-that is, the developing moral agencies and aspirations of learners to be good physicians. Evidence: Our conceptual analysis and argument build on a critical review of the medical education literature on PIF and draw on relevant insights from virtue ethics to deepen the conceptualization of PIF in moral, and not just psychosocial, terms. We show that a narrowly psychosocial view risks perpetuating institutional perceptions that can conceive professionalism norms primarily as standards of discipline or social control. By drawing on the conceptual resources of virtue ethics, we highlight not just the psychosocial development of medical learners but also their self-reflective, critical development as particular moral agents aspiring to embody the excellences of a good physician and, ultimately, to exhibit those traits and behaviors in the practice of medicine. Implications: We consider the pedagogical relevance of this insight. We show that drawing on virtue theory can more adequately orient medical pedagogy to socialize learners into the medical community in ways that nurture their personal growth as moral agents-in terms of their particular, restless aspirations to be a good physician and to flourish as such.
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Affiliation(s)
- Daniel T Kim
- Alden March Bioethics Institute, Albany Medical College, Albany, New York, USA
| | - Megan K Applewhite
- Alden March Bioethics Institute, Albany Medical College, Albany, New York, USA
| | - Wayne Shelton
- Alden March Bioethics Institute, Albany Medical College, Albany, New York, USA
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Kaldjian LC, Yoon J, Ark TK, Shinkunas L, Jotterand F. Practical wisdom in medicine through the eyes of medical students and physicians. MEDICAL EDUCATION 2023; 57:1219-1229. [PMID: 37118991 DOI: 10.1111/medu.15108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/28/2023] [Accepted: 04/14/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Practical wisdom is considered a multidimensional virtue of enduring relevance to medicine. Though it has received increasing attention in recent years, proposed frameworks for practical wisdom can differ, and little is known about how medical students and physicians describe its dimensions and relevance. METHODS We used structured interviews, employing open-ended and closed-ended questions, to describe how medical students and physicians understand practical wisdom and identify the kinds of clinical situations they believe require practical wisdom. We interviewed 102 participants at two US medical schools in 2021, comprising a voluntary response sample of 40 pre-clinical medical students and 40 clinical medical students and a purposive sample of 22 nominated physicians. Interviews were conducted by videoconference using a structured interview guide. Open-ended responses were coded using qualitative content analysis (directed and conventional) and tabulated; closed-ended responses were tabulated. Quotations provided qualitative illustrations, and frequencies were used for summative results. RESULTS Participants considered practical wisdom clinically meaningful, broadly relevant and multidimensional. Most described it as deliberative, goal-directed, context-sensitive, integrated with ethics and marked by integrity and motivation to act. Many described it as experience-based, person-centred or problem-solving. Participants also selected an average of 15.6 (SD = 4.9) additional virtues as being essential for practical wisdom in medicine and described a broad range of clinical situations that require practical wisdom in medicine. CONCLUSIONS Participants described practical wisdom as a multidimensional capacity that entails deliberation, depends on a constellation of other virtues and is broadly applicable to medicine. Most agreed it is goal-directed and context-sensitive and involves ethics, integrity and motivation. Efforts to teach practical wisdom in medical education should clarify its dimensions and highlight its relationship to virtue ethics, professionalism, clinical judgement and the individualised care of patients as persons.
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Affiliation(s)
- Lauris C Kaldjian
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - John Yoon
- MacLean Center of Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA
- Program on Medicine and Religion, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
- Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Tavinder K Ark
- Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Laura Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Fabrice Jotterand
- Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for Bioethics and Medical Humanities, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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Verstegen PMB, Kole JJ(J, Groenewoud AS, van den Hoogen FJA. Virtues in Competency-Based Assessment Frameworks: A Text Analysis. PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:418-426. [PMID: 37868074 PMCID: PMC10588518 DOI: 10.5334/pme.996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/08/2023] [Indexed: 10/24/2023]
Abstract
Introduction Official documentation of specialty training provides comprehensive and elaborate criteria to assess residents. These criteria are commonly described in terms of competency roles and entrustable professional activities (EPA's), but they may also implicitly encompass virtues. Virtues are desirable personal qualities that enable a person, in this case, a medical specialist, to make and act on the right decisions. We articulate these virtues and explore the resulting implied ideal of a medical professional. Method We applied a two-staged virtue ethical content analysis to analyze documents, specific to the Dutch training program of the Ear, Nose, and Throat (ENT) specialty. First, we identified explicit references to virtues. Next, we articulated implicit virtues through interpretation. The results were categorized into cardinal, intellectual, moral, and professional virtues. Results Thirty virtues were identified in the ENT- training program. Amongst them, practical wisdom, temperance, and commitment. Furthermore, integrity, curiosity, flexibility, attentiveness, trustworthiness and calmness are often implicitly assumed. Notable findings are the emphasis on efficiency and effectiveness. Together, these virtues depict an ideal of a future medical specialist. Conclusion Our findings suggest that competency-frameworks and EPA's implicitly appeal to virtues and articulate a specific ideal surgeon. Explicit attention for virtue development and discussion of the role and relevance of implied ideal professionals in terms of virtues could further improve specialty training.
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Affiliation(s)
- Pleuntje M. B. Verstegen
- Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - J. J. (Jos) Kole
- Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - A. Stef Groenewoud
- Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Abstract
Consumer medicine consists of medical interventions pursued for non-health-related goals with the locus of the goals residing solely with the patient. Currently, contraceptives, abortion, cosmetic procedures, and physician-assisted suicide (PAS)/euthanasia fall in this category. Consumer medicine originates from the fusion of expressive individualism with its sole focus on the subjective psychological well-being intersecting with an expansion of health now including well-being combined with an exaltation of autonomy. Expressive individualism is inward-focused and entirely subjective reducing the human to a psychologic self while instrumentalizing the biological and social dimensions and neglecting the spiritual dimension. Expressive individualism is currently manifested through economic activity (career and consumption) and particularly sexual expression. This contrasts with the holistic biopsychosocial-spiritual model of health with its deep inter-relationships and prioritization of the spiritual. Consumer medicine has damaged the profession of medicine. Physicians now have conflicting roles of healer versus body engineer, and conflicting obligations to do no harm while performing medical harms unrelated to objective health. There is now division within medicine and increasing external state regulations both seriously harming its professional status. The traditional teleologically driven ethical framework that is objectively disease-focused is now confused with a subjective list of non-health-related values as goals for medical interventions leading to an incoherent ethical framework. Biologic solutions best address biological problems and do not effectively address psychological, social, or even spiritual problems but rather make them worse. Medicine now reinforces and is complicit with expressive individualism and its attendant shallow and narrow understanding of what it means to be human with the current valuation of sexual expression and economic activity. Medical harms and social costs have resulted while challenging the value of those who are disabled, elderly, or marginalized. This shallow view has likely fueled the current existential crisis contributing to the marked increase in PAS/euthanasia in the West. Summary: Consumer medicine currently includes contraceptives, abortion, cosmetic procedures, and physician-assisted suicide (PAS)/euthanasia. These medical interventions are pursued for subjective non-health-related goals as opposed to the traditional goal of treating sick patients for their objective health. Consumer medicine's origins lie in the intersection of expressive individualism, the exaltation of patient autonomy combined with health's redefinition as subjective well-being. This has resulted in harms to the profession of medicine, ethical incoherence, and medical injury. Consumer medicine promotes a truncated understanding of the human at odds with the biopsychosocial-spiritual model and human flourishing. This has likely contributed to the rise of PAS/euthanasia.
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Affiliation(s)
- Christopher J. Lisanti
- Department of Radiology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
- Department of Radiology and Radiological Sciences, USUHS, Bethesda, MD, USA
- Pregnancy Care Center, San Antonio, TX, USA
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Huber A, Strecker C, Kachel T, Höge T, Höfer S. Character Strengths Profiles in Medical Professionals and Their Impact on Well-Being. Front Psychol 2020; 11:566728. [PMID: 33424679 PMCID: PMC7786021 DOI: 10.3389/fpsyg.2020.566728] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 12/04/2020] [Indexed: 11/13/2022] Open
Abstract
Character strengths profiles in the specific setting of medical professionals are widely unchartered territory. This paper focused on an overview of character strengths profiles of medical professionals (medical students and physicians) based on literature research and available empirical data illustrating their impact on well-being and work engagement. A literature research was conducted and the majority of peer-reviewed considered articles dealt with theoretical or conceptually driven 'virtues' associated with medical specialties or questions of ethics in patient care (e.g., professionalism, or what makes a good physician). The virtues of compassion, courage, altruism, and benevolence were described most often. Only a limited number of papers addressed character strengths of medical students or physicians according to the VIA-classification. Those articles showed that the VIA-character strengths fairness, honesty, kindness, and teamwork were considered most often by respondents to be particularly important for the medical profession. Available cross-sectional (time span: six years) and longitudinal (time span: three years) data regarding VIA-character strengths profiles of medical professionals were analyzed (N = 584 medical students, 274 physicians). These profiles were quite homogenous among both groups. The character strengths fairness, honesty, judgment, kindness, and love had the highest means in both samples. Noteworthy differences appeared when comparing medical specialties, in particular concerning general surgeons and psychiatrists, with the former reporting clearly higher levels of e.g., honesty (d = 1.02) or prudence (d = 1.19). Long-term results revealed significant positive effects of character strengths on well-being and work engagement (e.g., perseverance on physicians' work engagement) but also significant negative effects (e.g., appreciation of beauty and excellence on students' well-being). Further, hope was significantly associated both positively with physicians' well-being and negatively with students' work engagement, possibly indicating specific issues concerning medical education or hospital working conditions. According to the modern-day physician's pledge, medical professionals should pay attention to their own well-being and health. Therefore, promoting self-awareness and character building among medical professionals could be a beneficial strategy.
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Affiliation(s)
- Alexandra Huber
- Department of Medical Psychology, Medical University of Innsbruck, Innsbruck, Austria
| | - Cornelia Strecker
- Institute of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Timo Kachel
- Institute of Psychology, University of Innsbruck, Innsbruck, Austria
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Höge
- Institute of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Stefan Höfer
- Department of Medical Psychology, Medical University of Innsbruck, Innsbruck, Austria
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Hawking M, Kim J, Jih M, Hu C, Yoon JD. "Can virtue be taught?": a content analysis of medical students' opinions of the professional and ethical challenges to their professional identity formation. BMC MEDICAL EDUCATION 2020; 20:380. [PMID: 33092593 PMCID: PMC7584068 DOI: 10.1186/s12909-020-02313-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/16/2020] [Indexed: 05/21/2023]
Abstract
BACKGROUND Efforts have begun to characterize the ethical and professional issues encountered by medical students in their clinical years. By applying previously identified taxonomies to a national sample of medical students, this study seeks to develop generalizable insights that can inform professional identity formation across various clerkships and medical institutions. METHODS In a national survey of medical students, participants answered an open-ended survey item that asked them to describe a clinical experience involving an ethical or professional issue. We conducted a content analysis with these responses using the Kaldjian taxonomy of ethical and professionalism themes in medical education through an iterative, consensus-building process. Noting the emerging virtues-based approach to ethics and professionalism, we also reexamined the data using a taxonomy of virtues. RESULTS The response rate to this survey item was 144 out of 499 eligible respondents (28.9%). All 144 responses were successfully coded under one or more themes in the original taxonomy of ethical and professional issues, resulting in a total of 173 coded responses. Professional duties was the most frequently coded theme (29.2%), followed by Communication (26.4%), Quality of care (18.8%), Student-specific issues of moral distress (16.7%), Decisions regarding treatment (16.0%), and Justice (13.2%). In the virtues taxonomy, 180 total responses were coded from the 144 original responses, and the most frequent virtue coded was Wisdom (23.6%), followed by Respectfulness (20.1%) and Compassion or Empathy (13.9%). CONCLUSIONS Originally developed from students' clinical experiences in one institution, the Kaldjian taxonomy appears to serve as a useful analytical framework for categorizing a variety of clinical experiences faced by a national sample of medical students. This study also supports the development of virtue-based programs that focus on cultivating the virtue of wisdom in the practice of medicine.
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Affiliation(s)
- Michael Hawking
- Hematology and Oncology, The University of Chicago, Chicago, IL, USA
| | - Jenny Kim
- Department of Biological Sciences, The University of Chicago, Chicago, IL, USA
| | - Melody Jih
- Department of Economics, The University of Chicago, Chicago, IL, USA
| | - Chelsea Hu
- Department of Economics and the Department of Political Science, The University of Chicago, Chicago, IL, USA
| | - John D Yoon
- MacLean Center for Clinical Medical Ethics, Department of Medicine, The University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
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Kaldjian LC. Practising the ethics we teach in international medical education. MEDICAL EDUCATION 2020; 54:384-386. [PMID: 32119149 DOI: 10.1111/medu.14143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 02/25/2020] [Indexed: 06/10/2023]
Affiliation(s)
- Lauris C Kaldjian
- Program in Bioethics and Humanities, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Oath to Self-Care and Well-Being. Am J Med 2020; 133:249-252.e1. [PMID: 31647911 DOI: 10.1016/j.amjmed.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/26/2019] [Accepted: 10/11/2019] [Indexed: 01/17/2023]
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Kaldjian LC, Shinkunas LA, Reisinger HS, Polacco MA, Perencevich EN. Attitudes about sickness presenteeism in medical training: is there a hidden curriculum? Antimicrob Resist Infect Control 2019; 8:149. [PMID: 31508227 PMCID: PMC6727412 DOI: 10.1186/s13756-019-0602-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/23/2019] [Indexed: 11/24/2022] Open
Abstract
Background Sickness presenteeism among healthcare professionals can compromise patient safety. To better understand what motivates this phenomenon, especially among trainees, the authors investigated attitudes of medical students, resident physicians, and faculty physicians about working when sick with what might be an infectious condition. Methods In 2012–2013, the authors employed a mixed methods, two-stage, cross-sectional survey at the University of Iowa Hospitals and Clinics of medical students (third-year students in the first survey and fourth-year students in the second survey), resident physicians in Internal Medicine, Pediatrics, and Family Medicine (first-year residents in the first survey and second-year residents in the second survey), and faculty physicians in Internal Medicine, Pediatrics, and Family Medicine. The first survey included one open-ended question querying attitudes about sickness presenteeism, answers to which underwent content analysis that identified 17 codes used to develop 23 additional closed-ended questions for a second survey. Results 127 participants completed the second survey (44% response rate). Sixty percent of these participants felt obligated to work when sick; and 33% felt obligated to work with influenza-like symptoms (fever, myalgias, cough), with residents and students being more likely to do so than faculty (67% vs. 35% vs. 14%, p = 0.001). Most participants (83%) were motivated to work when sick to avoid creating more work for colleagues, and residents and students were more likely than faculty physicians to want to avoid negative repercussions (84% vs 71% vs. 25%, p < 0.001) or appear lazy or weak (89% vs 75% vs. 40%, p < 0.001). Most participants also recognized the need to avoid spreading infections to patients (81%) or colleagues (75%). Conclusions When deciding whether to work when sick, students, residents, and faculty report a mixture of motivations that focus on the interests of patients, colleagues, and themselves. Awareness of these mixed motivations, particularly among trainees, can help inform interventions aimed at limiting instances of sickness presenteeism to support a culture of patient safety and counter any tendencies toward a hidden curriculum of efficiency and achievement.
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Affiliation(s)
- Lauris C Kaldjian
- 1Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA USA.,2Program in Bioethics and Humanities, Carver College of Medicine, University of Iowa , 500 Newton Road, Iowa City, IA 52242 USA
| | - Laura A Shinkunas
- 2Program in Bioethics and Humanities, Carver College of Medicine, University of Iowa , 500 Newton Road, Iowa City, IA 52242 USA
| | - Heather Schacht Reisinger
- 1Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA USA.,3Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA USA
| | - Marc A Polacco
- 4Department of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Eli N Perencevich
- 1Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA USA.,3Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA USA
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Helmich E, de Carvalho‐Filho MA. Context, culture and beyond: medical oaths in a globalising world. MEDICAL EDUCATION 2018; 52:784-786. [PMID: 29992690 PMCID: PMC6055655 DOI: 10.1111/medu.13623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The authors argue oath taking to be an expression of context specific social processes and that seemingly universal concepts might be conceived variably.
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Affiliation(s)
- Esther Helmich
- Center for Education Development and Research in Health Professions, University Medical Center Groningen, University of GroningenGroningenthe Netherlands
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