Exploring patients' and physicians' perspectives about competent health advocacy

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.

Sustainability of an outcome measure in outpatient stroke rehabilitation: A realist evaluation

RATIONALE

Only half of newly implemented evidence-based practices are sustained. Though poor sustainment can lead to negative consequences for clinical teams, organizations and patients, the causal explanations of sustainment are largely unknown.

AIMS AND OBJECTIVES

We aimed to ascertain how (mechanisms) and in what circumstances (context) a newly implemented outcome measure in rehabilitation was sustained or not (outcome).

METHODOLOGY

Informed by an integrated knowledge translation approach, we conducted a realist evaluation using a mixed method, embedded single case study design with data collection up to 18 months following the implementation of the Mayo-Portland Adaptability Inventory - version 4 (MPAI-4), a rehabilitation outcome measure. Quantitative data (survey and patient charts) was analysed using descriptive statistics, then integrated with qualitative data (interviews with 10 key informants) and analysed using inductive and deductive retroduction. We integrated the data to develop a case description and ultimately, to refine the programme theory to better understand the sustainability of the MPAI-4.

RESULTS

We linked context, mechanisms and outcomes, and also emphasized sustainability strategies in 18 explanations of how sustainability works. These explanations provide evidence for four overarching patterns: (1) implementation and sustainability phases are interconnected, (2) outcomes build on each other recursively, with patient benefits as the keystone outcome, (3) sustainment is achieved to varying levels across different sustainability outcomes [e.g., high level (e.g., rate of MPAI-4 scoring: 77.7%) to low level (e.g., rate of MPAI-4 application to clinical decision-making: 3.7%)] and (4) the work of sustaining the MPAI-4 is shared amongst different stakeholders.

CONCLUSION

Implementation teams can draw from this programme theory to improve the sustainment of outcomes measures while researchers could continue to refine the theory. Continued investigation of sustainability, including diverse and continuous sustainability outcomes, is needed to understand how to maintain improvements in quality of care and patient outcomes.

How Are We Teaching Advocacy? A National Survey of Internal Medicine Residency Program Directors

BACKGROUND

Although internal medicine (IM) physicians accept public advocacy as a professional responsibility, there is little evidence that IM training programs teach advocacy skills. The prevalence and characteristics of public advocacy curricula in US IM residency programs are unknown.

OBJECTIVES

To describe the prevalence and characteristics of curricula in US IM residencies addressing public advocacy for communities and populations; to describe barriers to the provision of such curricula.

DESIGN

Nationally representative, web-based, cross-sectional survey of IM residency program directors with membership in an academic professional association.

PARTICIPANTS

A total of 276 IM residency program directors (61%) responded between August and December 2022.

MAIN MEASUREMENTS

Percentage of US IM residency programs that teach advocacy curricula; characteristics of advocacy curricula; perceptions of barriers to teaching advocacy.

KEY RESULTS

More than half of respondents reported that their programs offer no advocacy curricula (148/276, 53.6%). Ninety-five programs (95/276, 34.4%) reported required advocacy curricula; 33 programs (33/276, 12%) provided curricula as elective only. The content, structure, and teaching methods of advocacy curricula in IM programs were heterogeneous; experiential learning in required curricula was low (23/95, 24.2%) compared to that in elective curricula (51/65, 78.5%). The most highly reported barriers to implementing or improving upon advocacy curricula (multiple responses allowed) were lack of faculty expertise in advocacy (200/276, 72%), inadequate faculty time (190/276, 69%), and limited curricular flexibility (148/276, 54%).

CONCLUSION

Over half of US IM residency programs offer no formal training in public advocacy skills and many reported lack of faculty expertise in public advocacy as a barrier. These findings suggest many IM residents are not taught how to advocate for communities and populations. Further, less than one-quarter of required curricula in public advocacy involves experiential learning.

Understanding the lived-experience and support-needs of people living with antimicrobial resistance in the UK through interpretative phenomenological analysis

In the UK nearly 54,000 infections were caused by serious resistant bacteria in 2022 but there is a lack of evidence regarding the long-term impact on patients' lives nor what support they need. This research aimed to answer the question: "What are the key elements of experience and support needs of people living with AMR in the UK?". In-depth semi-structured interviews were undertaken with nine people who had been living with resistant infections or colonisation for 12-months or longer. Interpretive Phenomenological Analysis was used to study the accounts and illustrate individuals' experiences and support-needs. Participants experienced marginalisation and isolation but also empowerment; described across three major themes: (1) I live in fear and stigma: The long-term impact of AMR; (2) I am battling on my own: A journey toward self-advocacy; and (3) I like to share my story: The role of AMR communities. All participants perceived a lack of knowledge, information, and support from clinicians; difficulties accessing reliable and understandable information; and lack of understanding from family and friends. Charities and online groups provided support with coping with their situation and improving mental health and wellbeing. Understandable and relatable information regarding the science of AMR, transmission, prevention, and living with AMR needs to be provided by clinicians and healthcare services around the time of diagnosis to readily available after diagnosis.

Set Up to Fail? Barriers Impeding Resident Communication Training in Neonatal Intensive Care Units

PURPOSE

Learning to navigate difficult clinical conversations is an essential feature of residency training, yet much of this learning occurs "on the job," often without the formative, multisource feedback trainees need. To generate insight into how on-the-job training influences trainee performance, the perspectives of parents and health care providers (HCPs) who engaged in or observed difficult conversations with Neonatal Intensive Care Unit (NICU) trainees were explored.

METHOD

The iterative data generation and analysis process was informed by constructivist grounded theory. Parents (n = 14) and HCPs (n = 10) from 2 Canadian NICUs were invited to participate in semistructured interviews informed by rich pictures-a visual elicitation technique useful for exploring complex phenomena like difficult conversations. Themes were identified using the constant comparative approach. The study was conducted between 2018 and 2021.

RESULTS

According to participants, misalignment between parents' and trainees' communication styles, HCPs intervening to protect parents when trainee-led communication went awry, the absence of feedback, and a culture of sole physician responsibility for communication all conspired against trainees trying to develop communication competence in the NICU. Given beliefs that trainees' experiential learning should not trump parents' well-being, some physicians perceived the art of communication was best learned by observing experts. Sometimes, already limited opportunities for trainees to lead conversations were further constricted by perceptions that trainees lacked the interest and motivation to focus on so-called "soft" skills like communication during their training.

CONCLUSIONS

Parents and NICU staff described that trainees face multiple barriers against learning to navigate difficult conversations that may set them up to fail. A deeper understanding of the layered challenges trainees face, and the hierarchies and sociocultural norms that interfere with teaching, may be the start of breaking down multiple barriers trainees and their clinician supervisors need to overcome to succeed.

Analysis of the health advocacy concept from the perspective of the evolutionary method

OBJECTIVE

To analyze the concept of Health Advocacy from the methodological framework of the Evolutionary Model.

METHOD

The concept of interest was evaluated from the perspective of published studies identified in the databases: Web of Science, CINAHL, EMBASE, SCOPUS, MEDLINE and articles of interest. The attributes were determined from 19 scientific productions. Data were analyzed using thematic analysis, proposed by Bardin.

RESULTS

The following operational definition was obtained: Health Advocacy is an intentional action, implemented jointly and in favor of individuals and communities, especially for those who suffer from health inequalities, with the aim of preserving and improving health, well-being and empowerment for health promotion.

FINAL CONSIDERATIONS

Thus, a broader concept of Health Advocacy was abstracted, from the micro to the macro, which contemplates the development of the patient's autonomy; includes individuals and groups in care plans and involves them in political activities as possibilities to provide assistance and correct health inequalities.

Advocacy Curricula in Graduate Medical Education: an Updated Systematic Review from 2017 to 2022

BACKGROUND

Advocacy is an integral component of a physician's professional responsibilities, yet efforts to teach advocacy skills in a systematic and comprehensive manner have been inconsistent and challenging. There is currently no consensus on the tools and content that should be included in advocacy curricula for graduate medical trainees.

OBJECTIVE

To conduct a systematic review of recently published GME advocacy curricula and delineate foundational concepts and topics in advocacy education that are pertinent to trainees across specialties and career paths.

METHODS

We conducted an updated systematic review based off Howell et al. (J Gen Intern Med 34(11):2592-2601, 2019) to identify articles published between September 2017 and March 2022 that described GME advocacy curricula developed in the USA and Canada. Searches of grey literature were used to find citations potentially missed by the search strategy. Articles were independently reviewed by two authors to identify those meeting our inclusion and exclusion criteria; a third author resolved discrepancies. Three reviewers used a web-based interface to extract curricular details from the final selection of articles. Two reviewers conducted a detailed analysis of recurring themes in curricular design and implementation.

RESULTS

Of 867 articles reviewed, 26 articles, describing 31 unique curricula, met inclusion and exclusion criteria. The majority (84%) represented Internal Medicine, Family Medicine, Pediatrics, and Psychiatry programs. The most common learning methods included experiential learning, didactics, and project-based work. Most covered community partnerships (58%) and legislative advocacy (58%) as advocacy tools and social determinants of health (58%) as an educational topic. Evaluation results were inconsistently reported. Analysis of recurring themes showed that advocacy curricula benefit from an overarching culture supportive of advocacy education and should ideally be learner-centric, educator-friendly, and action-oriented.

DISCUSSION

Combining core features of advocacy curricula identified in prior publications with our findings, we propose an integrative framework to guide design and implementation of advocacy curricula for GME trainees. Additional research is needed to build expert consensus and ultimately develop model curricula for disseminated use.

Expanding the advocacy lens: using photo-elicitation to capture patients' and physicians' perspectives about health advocacy

Heath advocacy (HA) remains a difficult competency to train and assess, in part because practicing physicians and learners carry uncertainty about what HA means and we are missing patients' perspectives about the role HA plays in their care. Visual methods are useful tools for exploring nebulous topics in health professions education; using these participatory approaches with physicians and patients might counteract the identified training challenges around HA and more importantly, remedy the exclusion of patient perspectives. In this paper we share the verbal and visual reflections of patients and physicians regarding their conceptualizations of, and engagement in 'everyday' advocacy. In doing so, we reveal some of HA's hidden dimensions and what their images uncovered about the role of advocacy in patient care. Constructivist grounded theory guided data collection and analysis. Data was collected through semi-structured interviews and photo-elicitation, a visual research method that uses participant generated photographs to elicit participants knowledge and experiences around a particular topic. We invited patients living with chronic health conditions (n = 10) and physicians from diverse medical and surgical specialties (n = 14) to self-select photographs representing their experiences navigating HA in their personal and professional lives. Both groups found taking photographs useful for revealing the nuanced and circumstantial factors that either enabled or challenged their engagement in HA. While patients' photos highlighted their embodiment of HA, physicians' photos depicted HA as something quite elusive or as a complicated and daunting task. Photo-elicitation was a powerful tool in eliciting a diversity of perspectives that exist around the HA role and the work advocates perform; training programs might consider using visuals to augment teaching for this challenging competency.

Grappling with key questions about assessment of the Health Advocate role

Introduction

Although the CanMEDS framework sets the standard for Canadian training, health advocacy competence does not appear to factor heavily into high stakes assessment decisions. Without forces motivating uptake, there is little movement by educational programs to integrate robust advocacy teaching and assessment practices. However, by adopting CanMEDS, the Canadian medical education community endorses that advocacy is required for competent medical practice. It's time to back up that endorsement with meaningful action. Our purpose was to aid this work by answering the key questions that continue to challenge training for this intrinsic physician role.

Methods

We used a critical review methodology to both examine literature relevant to the complexities impeding robust advocacy assessment, and develop recommendations. Our review moved iteratively through five phases: focusing the question, searching the literature, appraising and selecting sources, and analyzing results.

Results

Improving advocacy training relies, in part, on the medical education community developing a shared vision of the Health Advocate (HA) role, designing, implementing, and integrating developmentally appropriate curricula, and considering ethical implications of assessing a role that may be risky to enact.

Conclusion

Changes to assessment could be a key driver of curricular change for the HA role, provided implementation timelines and resources are sufficient to make necessary changes meaningful. To truly be meaningful, however, advocacy first needs to be perceived as valuable. Our recommendations are intended as a roadmap for transforming advocacy from a theoretical and aspirational value into one viewed as having both practical relevance and consequential implications.

A Model of Advocacy to Inform Action

The need for effective advocacy on the part of health professionals has never been greater. The recent COVID-19 pandemic has made the connection between human health and social conditions clear, while highlighting the limitations of biomedical interventions to address those conditions. Efforts to increase the frequency and effectiveness of advocacy activities by health professionals have been hampered by the lack of a practical framework to define and develop advocacy competencies among trainees as well as to plan and execute advocacy activities. The authors of this article propose a framework which defines advocacy as occurring across three domains of influence (practice, community, and government) using three categories of advocacy skills (policy, communication, and relationships). When these skills are successfully applied in the appropriate domains of influence, the resulting change falls into three levels: individual, adjacent, and structural. The authors assert that this framework is immediately applicable to a broad variety of health professionals, educators, researchers, organizations, and professional societies as they individually and collectively seek to improve the health and well-being of those they care for.

Health advocacy among medical learners: Unpacking contextual barriers and affordances

INTRODUCTION

Learners and physicians are expected to practice as health advocates in Canadian contexts, but they rarely feel competent to practice this critical role when they complete their training. This is in part because advocacy is seen as "going above and beyond" routine practice and pushing the boundaries of systems that are resistant to change. Medical learning contexts are rife with barriers to learning about and practicing advocacy, and there is now a need to understand how contexts impact advocacy.

METHODS

Using constructivist grounded theory study, we generated data through individual and group interviews with medical learners to explore the barriers and facilitators to advocacy in a variety of learning/practice contexts. We used purposeful and theoretical sampling to ensure that diverse learning contexts and learners who had different views on advocacy were represented. We constructed a theoretical model to understand advocacy decision-making through cycles of initial, focused and theoretical coding, using constant comparative analysis.

RESULTS

Learners' thinking about health advocacy was framed by their own unique knowledge and beliefs, as well as their institutional and organisational contexts. With these influences in mind, learners made decisions about when to advocate within a local decision-making context, guided by affordances and barriers to advocacy involved in their perceptions of the patient, their own social position, resources available and social norms.

CONCLUSIONS

This framework highlights critical aspects of context that influence learners' ability to learn about and practice as health advocates. If we are to adequately prepare learners for this important work, we must address aspects of their learning and practice contexts that make this work daunting, and we offer learners the tools required to intervene in contexts that do not support their efforts.

Medical Student Identity Construction Within Longitudinal Integrated Clerkships: An International, Longitudinal Qualitative Study

PURPOSE

Longitudinal integrated clerkships (LICs) have been implemented worldwide to increase authentic student participation in patient care over time. Studies have shown benefits of the model include the ability of LICs to attract future practitioners to underserved areas, student engagement in advocacy, and development of an "ethic of caring." Less is known, however, about how LICs impart their benefits, although LICs may strengthen professional identity. As such, this study aimed to explore medical student professional identity construction through time within LICs internationally.

METHOD

This was a longitudinal qualitative study from 2019 to 2020, involving 33 students across 4 medical schools in the United Kingdom, Ireland, and the United States. The authors explored participating students' identity construction during LICs. Data collection involved 3 stages: individual, semistructured interviews at entry (n = 33) and exit of the LIC (n = 29), and audio diaries throughout. Data were analyzed inductively using a reflexive thematic approach.

RESULTS

Three themes were identified. Longitudinal relationships with patients and preceptors encouraged patient care ownership and responsibility; LIC students identified as patient advocates; and longitudinal relationships shaped students' social consciences. Themes were underpinned by continuity of relationships between students and patients, and students and tutors.

CONCLUSIONS

Though continuity is lauded as the cornerstone of LICs, these findings suggest that this is too broad a way of understanding the benefits of LICs. Instead, continuity should be seen as facilitating the development of important relationships within diverse communities of practice, which leads medical students to construct professional identities as responsible, compassionate advocates for underserved populations. This was the case across the institutions, nations, and LIC types in this study. By highlighting the ways in which LICs influence identity, these findings offer important insight relating to the future development and delivery of LICs.

Normalising disclosure or reinforcing heroism? An exploratory critical discourse analysis of mental health stigma in medical education

INTRODUCTION

There has been a proliferation of initiatives targeted towards improving psychological wellbeing among medical learners. Yet many learners do not seek assistance due to stigma against help seeking. Understanding the prevailing discourses on the effects of mental health stigma in the context of medical education will improve insight on how to address stigma and improve wellbeing. In this study, the authors sought to explore discourses on stigma in medical education through a Foucauldian Critical Discourse Analysis.

METHODS

The authors assembled several sets of texts related to stigma in medical education. The initial archive consisted of social media discourse and was expanded to include digital news media. Next, the authors conducted semi-structured qualitative interviews with medical students, residents and faculty. Using principles of Critical Discourse Analysis informed by the writings of Michel Foucault, the authors analysed the archive to identify truth statements, representative statements and discursive effects.

RESULTS

Analysis revealed an emancipatory discourse of disclosure that normalised help-seeking, which conflicted with a discourse of performance. Results suggested that public disclosure remains challenging in private contexts due to a medical culture that rewards perfectionism and lauds heroism. Discourses on performance positioned disclosure as disruptive to the system's need to maintain its own hegemony. Overall, stigma was perceived as rooted within the structural power of the medical education system and society at large.

CONCLUSION

Discourses on stigma in medical education hold implications for the teaching, learning and overall wellbeing of medical learners. The tensions between discourses on disclosure and performance have the potential to perpetuate further distress for learners and worsen asymmetries in power. Interventions to address stigma would benefit from understanding and addressing the role of power and hierarchy in maintaining and dismantling stigma.

Patient involvement in assessment of postgraduate medical learners: A scoping review

CONTEXT

Competency-based assessment of learners may benefit from a more holistic, inclusive, approach for determining readiness for unsupervised practice. However, despite movements towards greater patient partnership in health care generally, inclusion of patients in postgraduate medical learners' assessment is largely absent.

METHODS

We conducted a scoping review to map the nature, extent and range of literature examining the inclusion (or exclusion) of patients within the assessment of postgraduate medical learners. Guided by Arskey and O'Malley's framework and informed by Levac et al. and Thomas et al., we searched two databases (MEDLINE® and Embase®) from inception until February 2021 using subheadings related to assessment, patients and postgraduate learners. Data analysis examined characteristics regarding the nature and factor influencing patient involvement in assessment.

RESULTS

We identified 41 papers spanning four decades. Some literature suggests patients are willing to be engaged in assessment, however choose not to engage when, for example, language barriers may exist. When stratified by specialty or clinical setting, the influence of factors such as gender, race, ethnicity or medical condition seems to remain consistent. Patients may participate in assessment as a stand-alone group or part of a multi-source feedback process. Patients generally provided high ratings but commented on the observed professional behaviours and communication skills in comparison with physicians who focused on medical expertise.

CONCLUSION

Factors that influence patient involvement in assessment are multifactorial including patients' willingness themselves, language and reading-comprehension challenges and available resources for training programmes to facilitate the integration of patient assessments. These barriers however are not insurmountable. While understudied, research examining patient involvement in assessment is increasing; however, our review suggests that the extent which the unique insights will be taken up in postgraduate medical education may be dependent on assessment systems readiness and, in particular, physician readiness to partner with patients in this way.

Online survey on factors influencing patients' motivation to undergo bariatric surgery

Given the worldwide increasing prevalence of severe obesity and considering the amount of scientific evidence demonstrating the beneficial effects of bariatric surgery (BS), it is surprising that only a fraction of patients with obesity undergo BS. We therefore conducted an anonymized online survey among individuals with a history of BS to understand factors influencing the deciding process leading to BS. Respondents were recruited on a voluntary basis from obesity-related social media groups between April and June 2020. The self-designed, non-validated questionnaire consisted of 20 questions and was open to any participants with a history of BS. Of 851 participants who started the survey, 665 completed the questionnaire (completion rate of 78.1%). Five years after BS, still 70% of the survey-participants were very satisfied or satisfied with the surgical result. However, the majority (73.3%) would have undergone BS earlier. The main motivation to choose BS was related to health status or quality of life. Important characteristics for a bariatric surgeon to obtain patients' trust are "taking time and listen" (74.7%), empathy (64%) and sympathy (56%). Post-operative satisfaction with the surgical outcome was high and long-lasting in this large cohort of BS patients. However, most participants would retrospectively have undergone BS earlier. The main reason to choose BS as treatment for their obesity were impaired physical health or reduced quality of life. Nearby location to patients' residence and availability of surgeons with empathy were decisive motives for bariatric centre selection.

Wrestling With the Invincibility Myth: Exploring Physicians' Resistance to Wellness and Resilience-Building Interventions

PURPOSE

Physicians are expected to provide compassionate, error-free care while navigating systemic challenges and organizational demands. Many are burning out. While organizations are scrambling to address the burnout crisis, physicians often resist interventions aimed at enhancing their wellness and building their resilience. The purpose of this research was to empirically study this phenomenon.

METHOD

Constructivist grounded theory was used to inform the iterative data collection and analysis process. In spring 2018, 22 faculty physicians working in Canada participated in semistructured interviews to discuss their experiences of wellness and burnout, their perceptions of wellness initiatives, and how their experiences and perceptions influence their uptake of the rapidly proliferating strategies aimed at nurturing their resilience. Themes were identified using constant comparative analysis.

RESULTS

Participants suggested that the values of compassion espoused by health care organizations do not extend to physicians, and they described feeling dehumanized by professional values steeped in an invincibility myth in which physicians are expected to be "superhuman" and "sacrifice everything" for medicine. Participants described that professional values and organizational norms impeded work-life balance, hindered personal and professional fulfillment, and discouraged disclosure of struggles. In turn, participants seemed to resist wellness and resilience-building interventions focused on fixing individuals rather than broader systemic, organizational, and professional issues. Participants perceived that efforts aimed at building individual resilience are futile without changes in professional values and sustained organizational support.

CONCLUSIONS

Findings suggest that professional and organizational norms and expectations trigger feelings of dehumanization for some physicians. These feelings likely exacerbate burnout and may partly explain physicians' resistance to resilience-building strategies. Mitigating burnout and developing and sustaining a resilient physician workforce will require both individual resistance to problematic professional values and an institutional commitment to creating a culture of compassion for patients and physicians alike.

Navigating the uncertainty of health advocacy teaching and evaluation from the trainee's perspective

BACKGROUND

There may be no competency more shrouded in uncertainty than health advocacy (HA), raising questions about the robustness of advocacy training in postgraduate medical education. By understanding how programs currently train HA, we can identify whether trainees' learning needs are being met.

METHODS

From 2017 to 2019, we reviewed curricular documents across nine direct-entry specialties at all Ontario medical schools, comparing content for the HA and communicator roles to delineate role-specific challenges. We then conducted semi-structured interviews with trainees (n = 9) and faculty (n = 6) to review findings and discuss their impact. Data were analyzed using thematic content analysis.

RESULTS

Curricular documents revealed vague objectives and ill-defined modes of assessment for both intrinsic roles. This uncertainty was perceived as more problematic for HA, in part because HA seemed both undervalued in, and disconnected from, clinical learning. Trainees felt that the onus was on them to figure out how to develop and demonstrate HA competence, causing many to turn their learning attention elsewhere.

DISCUSSION

Lack of curricular focus seems to create the perception that advocacy isn't valuable, deterring trainees-even those keen to become competent advocates-from developing HA skills. Such ambivalence may have troubling downstream effects for both patient care and trainees' professional development.

Drawing on experience: exploring the pedagogical possibilities of using rich pictures in health professions education

In both clinical and health professions education research, rich pictures, or participant-generated drawings of complex phenomena, are gaining recognition as a useful method for exploring multifaceted and emotional topics in medicine. For instance, two recent studies used rich pictures to augment semi-structured interviews exploring trainees', health care professionals' (HCPs), and parents' experiences of difficult conversations in the Neonatal Intensive Care Unit (NICU)-an environment in which communication is often challenging, anxiety-provoking, and emotionally distressing. In both studies, participants were invited to draw a picture depicting how they experienced a difficult conversation in this setting. As part of the interview process, participants were asked to both describe how they engaged with rich pictures, and to share their perceptions about the affordances and limitations of this research method. Here, their perspectives are reported and the possibilities of using rich pictures to inform pedagogical innovations in health professions education and research are considered.