"To obey or not to obey" - Medical students' response towards professional dilemmas in a hierarchical and collectivist culture

Nurturing humanism and professionalism in a clinical setting: A multicenter study to develop a framework for a learning module for clinical students

INTRODUCTION

Professionalism represents a contract between physicians and society, with humanism at its core. Humanism must be developed in medical education, especially in clinical settings, as students meet real-life professional situations. However, dynamic and unpredictable clinical settings might expose students to authentic yet unexpected far-from-ideal situations that might hinder the humanism and professionalism process. Furthermore, culture plays an influential role, highlighting the importance of developing an appropriate and contextual learning strategy. Hence, this study aims to conceptualize strategies to teach humanism and professionalism in high-power distance and collectivistic settings.

METHODS

This multicenter qualitative phenomenological study used maximum variation sampling to recruit participants, consisting of clinical students, teachers, and coordinators from three medical schools in Indonesia. Data were collected through focus group discussions (FGDs) and in-depth interviews. Thematic analysis was conducted using the steps of coding and theorization methods.

RESULTS

A total of 15 FGDs and one in-depth interview were conducted with 57 students, 39 teachers, and 18 coordinators. Socialization theory was used to analyze themes, leading to a culturally related approach to learning. Professional identity formation (PIF) was highlighted as the center of learning humanism and professionalism, with character building as the main principle. Designing a curriculum for humanism and professionalism for clinical learning should consider the longitudinal nature of PIF and ensure that professionalism explicitly exists in the curricula. As cultural impact might pose challenges, it must also be acknowledged and addressed. Meaningful integrated learning experiences, patient exposure, and reflection serve as the cornerstones of teaching-learning strategies while considering longitudinally explicit assessments.

CONCLUSION

Nurturing humanism and professionalism in undergraduate clinical settings is a longitudinal character-building process, with PIF as its center. Longitudinal, explicit, and dynamic strategies should be considered as part of the framework of teaching-learning and assessment of humanism and professionalism, as well as faculty development efforts with close attention to cultural factors.

Perceived Mistreatment and Professional Identity of Medical Students in China

Importance

Mistreatment is a common experience among medical students, with various negative consequences of such perceived mistreatment reported. However, few large-scale studies have investigated the association between perceived mistreatment and the formation of medical students' professional identities.

Objective

To investigate medical students' perceived mistreatment during medical school and its association with professional identity.

Design, Setting, and Participants

This repeated cross-sectional study included medical students graduating between 2019 and 2022 at 135 medical schools in China. Analyses were performed from July 25, 2023, to May 15, 2024.

Exposure

The China Medical Student Survey includes 5 items designed to measure students' perceived experiences of mistreatment.

Main Outcomes and Measures

Professional identity was measured using a validated 7-item scale adapted from the Macleod Clark Professional Identity Scale. Multivariate linear regression was used to determine the association between perceived mistreatment and medical students' professional identity.

Results

A total of 94 153 students (53 819 female [57.2%]; 83 548 Han ethnicity [88.7%]) were analyzed, representing 67.2% of the medical graduates enrolled in all responding medical schools. Most medical students reported having experienced at least 1 mistreatment incident (79 554 students [84.5%]). Medical students reported being required to perform personal service (57 455 students [61.0%]), experiencing mistreatment by patients (67 439 students [71.6%]), being publicly humiliated (24 348 students [25.9%]), being unjustly treated (35 926 students [38.2%]), and experiencing deliberate harassment (46 082 students [48.9%]). A negative association and saturation effect (where effect size plateaus after moderate exposure of mistreatment) were found between the degree of mistreatment and medical students' professional identity scores. Compared with students who had not reported mistreatment, students who reported single (β, -0.30; 95% CI, -0.33 to -0.28; P < .001), moderate (β, -0.66; 95% CI, -0.69 to -0.63; P < .001), and high (β, -0.62; 95% CI, -0.65 to -0.58; P < .001) frequency of mistreatment were more likely to have lower professional identity scores; this association persisted but was attenuated after adjusting for students' sociodemographic characteristics and was consistent across all the types of mistreatment.

Conclusions and Relevance

In this national, repeated cross-sectional study, a high prevalence of mistreatment among medical students in China and a negative association between perceived mistreatment and medical students' professional identity was found. Further research is needed to ensure that medical schools offer supportive and respectful learning environments.

Moral distress from professionalism dilemmas and its association with self-rated professionalism behaviors among Chinese residents

OBJECTIVES

Residents inevitably witness or participate in a diverse range of professionalism dilemmas. However, few studies have focused on residents' moral distress from professionalism dilemmas and its relationship with residents' professionalism. This study aimed to understand the moral distress that Chinese residents may face after exposure to professionalism dilemmas and to examine the associations between moral distress and residents' perceived fulfillment of professionalism behaviors.

METHODS

We conducted a cross-sectional survey of residents from four standardized residency training bases in Liaoning Province, China, using stratified cluster sampling. A checklist of professionalism dilemmas, the Moral Distress Scale, and the Behavior-based Medical Professionalism Inventory were used to assess residents' moral distress from professionalism dilemmas and their perceived fulfillment of professionalism behaviors. Descriptive statistics, non-parametric tests, multiple linear regressions, and binary logistic regressions were used to analyze the data.

RESULTS

A total of 647 (81.1%) residents effectively completed the survey. The proportion of residents suffering from moral distress ranged from 58.4 to 90.6% for different professionalism dilemmas. As the number of professionalism dilemmas associated with moral distress increased, residents reported lower fulfillment of professionalism behaviors (β < 0, p < 0.05). Compared with residents with no distress, residents suffering from distress reported lower fulfillment of professionalism behaviors (OR < 1, p < 0.05). Among residents suffering from distress, as the distress intensity increased, residents reported higher fulfillment of professionalism behaviors (OR > 1, p < 0.05).

CONCLUSIONS

Residents suffered a wide range of moral distress from professionalism dilemmas, and residents with moral distress reported lower fulfillment of professional behaviors. A responsive reporting system for residents and reflection on role modeling may help residents cope with the negative effects of moral distress and professionalism dilemmas.

Exploring a metacognitive approach for case analysis based learning of anxiety adjustment in nurses: a qualitative study

Objectives

This study aimed to investigate the effectiveness of a metacognitive learning program in enhancing nurses’ anxiety adjustment skills.

Methods

A qualitative exploratory study was conducted using semi-structured individual interviews with Japanese nurses who participated in a metacognitive learning program at Keio University Hospital. The program included a 90-minute classroom workshop followed by five online reflection sessions over three months. Participants were selected through purposive sampling, targeting those with at least four years of oncology nursing experience. Of the nine program participants, five met the inclusion criteria and consented to participate. Data were recorded and interviews transcribed three months post-program completion and analyzed using “Steps for Coding and Theorization.”

Results

Two main themes emerged from the analysis. The first theme, “Development of Metacognitive Understanding,” highlighted the participants' progress in comprehending metacognition through structured exercises and reflection. The second theme, “Cultivating Anxiety Adjustment Skills through Metacognition,” revealed improvements in coping with anxiety, including increased selfawareness, proactive strategies, and the application of metacognitive techniques in clinical practice.

Conclusions

This study found that metacognitive approaches could promote anxiety adjustment skills among nurses. Using learning scaffolds and reflecting on personal experiences, nurses could strengthen their metacognitive skills to adjust anxiety. These findings suggest that incorporating metacognitive approaches in nursing education could be beneficial. Future research should explore this approach in diverse clinical settings to generalize the results and examine the long-term impacts on nurses' anxiety management.

Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants

BACKGROUND

In the past, evidence-based medicine (EBM) and shared decision-making (SDM) have been taught separately in health sciences and medical education. However, recognition is increasing of the importance of EBM training that includes SDM, whereby practitioners incorporate all steps of EBM, including person-centered decision-making using SDM. However, there are few empirical investigations into the benefits of training that integrates EBM and SDM (EBM-SDM) for junior doctors, and their influencing factors. This study aimed to explore how integrated EBM-SDM training can influence junior doctors' attitudes to and practice of EBM and SDM; to identify the barriers and facilitators associated with junior doctors' EBM-SDM learning and practice; and to examine how supervising consultants' attitudes and authority impact on junior doctors' opportunities for EBM-SDM learning and practice.

METHODS

We developed and ran a series of EBM-SDM courses for junior doctors within a private healthcare setting with protected time for educational activities. Using an emergent qualitative design, we first conducted pre- and post-course semi-structured interviews with 12 junior doctors and thematically analysed the influence of an EBM-SDM course on their attitudes and practice of both EBM and SDM, and the barriers and facilitators to the integrated learning and practice of EBM and SDM. Based on the responses of junior doctors, we then conducted interviews with ten of their supervising consultants and used a second thematic analysis to understand the influence of consultants on junior doctors' EBM-SDM learning and practice.

RESULTS

Junior doctors appreciated EBM-SDM training that involved patient participation. After the training course, they intended to improve their skills in person-centered decision-making including SDM. However, junior doctors identified medical hierarchy, time factors, and lack of prior training as barriers to the learning and practice of EBM-SDM, whilst the private healthcare setting with protected learning time and supportive consultants were considered facilitators. Consultants had mixed attitudes towards EBM and SDM and varied perceptions of the role of junior doctors in either practice, both of which influenced the practice of junior doctors.

CONCLUSIONS

These findings suggested that future medical education and research should include training that integrates EBM and SDM that acknowledges the complex environment in which this training must be put into practice, and considers strategies to overcome barriers to the implementation of EBM-SDM learning in practice.

The hidden hurdles of clinical clerkship: unraveling the types and distribution of professionalism dilemmas among South Korean medical students

BACKGROUND

To improve the medical professionalism of medical students, it is essential to understand the dilemmas they face in various situations. This study explored the types and distribution of dilemmas Korean medical students encounter during their clinical clerkships. It then compared these with previous dilemma frameworks and identified the types and distribution of "complexity dilemmas," wherein two dilemma themes emerge in a single clinical situation.

METHODS

The researchers organized and recorded a group discussion with 106 third-year medical students who had completed their clinical clerkships. These students participated in the discussion as part of an assignment, focusing on the dilemmas they encountered during their clerkships. For data analysis and visualization, the researchers employed the MAXQDA software program and utilized the template analysis method, a qualitative research methodology.

RESULTS

A total of seven dilemma themes and sixteen sub-themes were identified. The identity-related dilemma concerning student-doctors had the highest frequency. The themes "mismatch" and "Nun-chi" emerged as new additions not found in previous dilemma frameworks. The complexity dilemmas appeared in the sequence of "identity-dignity," "identity-abuse," and "identity-consent".

CONCLUSIONS

To navigate the unique dilemmas present within South Korea's clinical culture, several key issues need consideration: elevating the role of student-doctors, balancing the primary emphasis of educational hospitals on delivering medical services, and understanding interpersonal strategies, such as "Nun-chi".

Challenges and opportunities in cultivating medical students' competencies: Participatory action research from a hierarchical cultural setting

BACKGROUNDS

Research concerning student-centered learning (SCL) recommends a comprehensive assessment of medical students' competencies including their personal and professional characters. Accordingly, nurturing future doctors should be in a continuous mentorship program. However, in a hierarchical culture, communication is one-way with limited feedback and reflection. We aimed to explore challenges and opportunities for SCL implementation in medical schools in this cultural setting necessary for a globally interdependent world.

METHODS

Two cycles of participatory action research (PAR) were conducted, involving medical students and teachers in Indonesia. A national conference on SCL principles was conducted between the cycles, also the SCL modules were developed for each institution and feedback was shared. Twelve focus group discussions were conducted (before and after the module development), with 37 medical teachers and 48 medical students from 7 faculties of medicine across Indonesia at various levels accreditation. Following verbatim transcriptions, a thematic analysis was conducted.

RESULTS AND DISCUSSIONS

In cycle 1 PAR, some challenges in implementing SCL were identified: lack of constructive feedback, overloaded content, summative-based assessment, hierarchical culture environment, and teachers' dilemma of committed time between patient-care and education. In cycle 2, several opportunities to approach the SCL were proposed: a faculty development program on mentorship, students' reflection guides and training, a more longitudinal assessment system, also a more supportive government policy on the human resources system.

CONCLUSIONS

The main challenge of fostering student-centered learning revealed in this study was a teacher-centered learning tendency in the medical curriculum. The weighting towards summative assessment and the national educational policy drive the curriculum like a 'domino effect', away from the expected student-centered learning principles. However, using a participative method, students and teachers could identify opportunities and articulate their educational needs, i.e., a partnership-mentorship program, as a significant step toward student-centered learning in this cultural context.

12 tips for introducing e-portfolios in undergraduate medical and dental curriculums

It is impossible to overlook the curricular advancements occurring all across the world. The evaluation methods should be revised in addition to the course objectives, programmes, and competences. If courses are evaluated the same way they have been in the past, we will not progress in education. We are on the verge of an educational revolution that will fundamentally alter how we educate and assess students. E-portfolios have now become recognized and valued by everyone in medical education and the workplace, including policymakers. For programmatic assessments, E-portfolios are the best supporting document one can use as a qualitative assessment. It can be used in many ways including career planning, assessment, and for structured feedback. E-Portfolio provides a secured database and then there are numerous ways to use this knowledge. It allows a learner to gather and exhibit proof of their accomplishments and proficiency in order to support the modern techniques of academic assessment. In this article, we suggest 12 tips for putting a portfolio programme for undergraduate students into practice. The suggestions are based on an extensive evaluation of the literature, and the authors' personal experiences helped lay the groundwork for the recommendations.

Exploring Professionalism Dilemma and Moral Distress through Medical Students' Eyes: A Mixed-Method Study

This study aims to understand professionalism dilemmas medical students have experienced during clinical clerkships and the resulting moral distress using an explanatory mixed-method sequential design-an anonymous survey followed by in-depth interviews. A total of 153 students completed and returned the survey, with a response rate of 21.7% (153/706). The top three most frequently occurring dilemmas were the healthcare team answering patients' questions inadequately (27.5%), providing fragmented care to patients (17.6%), and withholding information from a patient who requested it (13.7%). Students felt moderately to severely distressed when they observed a ward mate make sexually inappropriate remarks (81.7%), were pressured by a senior doctor to perform a procedure they did not feel qualified to do (77.1%), and observed a ward mate inappropriately touching a patient, family member, other staff, or student (71.9%). The thematic analysis based on nine in-depth interviews revealed the details of clinicians' unprofessional behaviors towards patients, including verbal abuse, unconsented physical examinations, bias in clinical decisions, students' inaction towards the dilemmas, and students' perceived need for more guidance in applying bioethics and professionalism knowledge. Study findings provide medical educators insights into designing a professional development teaching that equips students with coping skills to deal with professionalism dilemmas.

Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture

BACKGROUND

Professional identity formation (PIF) has been recognized as an integral part of professional development in medical education. PIF is dynamic: it occurs longitudinally and requires immersion in the socialization process. Consequently, in the medical education context, it is vital to foster a nurturing learning environment that facilitates PIF.

AIM

This study assesses PIF among medical students in various stages of study and explores their perceptions of PIF, with its contributing and inhibiting factors.

METHOD

This mixed-methods study uses a sequential explanatory approach with undergraduate (years 2, 4, and 6) and postgraduate medical students in Indonesia. We examine the subjects by administering an adapted questionnaire on PIF. We completed a series of FGDs following questionnaire administration. Quantitative and thematic analyses were conducted sequentially.

RESULTS & DISCUSSION

A total of 433 respondents completed the questionnaire. There were statistically significant differences among subjects on the subscales "Recognition and internalization of professional roles" and "Self-control in professional behavior"; the more senior students had higher scores. We conducted 6 FGDs in total. The results characterize PIF as a complex, dynamic, and longitudinal journey to becoming a medical doctor that is closely related to a student's motivation. The FGDs also highlight the importance of both internal factors (students' values, attributes, and personal circumstances) and external factors (curriculum, the learning environment, workplace-based learning, and external expectations) for PIF in medical education.

CONCLUSION

Higher-level students show higher scores in some aspects of PIF, which further validates the potential use of the questionnaire to monitor PIF, a dynamic process influenced by internal and external factors. Generating awareness among medical students and encouraging reflection on their PIF stage may be crucial for PIF processes.

Symptoms of depression and anxiety in Indonesian medical students: association with coping strategy and resilience

BACKGROUND

Depression and anxiety are prevalent mental health issues among medical students due to the various challenges during medical education. These issues affect not only their quality of life, but also their academic and professional development. Coping strategy and resilience are two factors that may influence students' mental health outcomes. Data of medical student mental health in Indonesia is scarce, hampering efforts to systematically address the problem. Hence, this study aims to estimate the prevalence of depressive and anxiety symptoms in Indonesian medical students, and their association with coping strategy and resilience.

METHODS

Undergraduate medical students from each year of study (Preclinical Year 1 to 4, Clinical Year 1 and 2) in the Faculty of Medicine Universitas Indonesia were randomly selected to participate in this cross-sectional study. The study questionnaire included sociodemographic characteristics, Depression Anxiety Stress Scale (DASS) to measure symptoms of depression and anxiety, Brief COPE to measure coping strategy, and Connor-Davidson Resilience Scale (CD-RISC) to measure resilience. Scores of depression and anxiety symptoms were analyzed by comparing them between different sociodemographic groups and by measuring their correlation with coping strategies and resilience. Multiple regression analyses were conducted to identify predictors of depression and anxiety symptoms.

RESULTS

Among 532 respondents, 22.2% reported symptoms of depression and 48,1% reported anxiety, including 3.0% and 8.1% with extremely severe depression and anxiety, respectively. Students not living with immediate family had higher depression score; female students and those in Preclinical Year 1 and Clinical Year 1 showed higher anxiety scores. Dysfunctional coping strategies and lower resilience are predictors of higher depression and anxiety symptoms.

CONCLUSIONS

Students show different levels of depressive and anxiety symptoms, signifying different levels of mental health support needs from universal mental health promotion to psychiatric treatment. Prevention programs can be targeted towards students with risk factors, such as not living with immediate family, undergoing first year of preclinical studies or clinical rotations, coping with dysfunctional strategies, and having low resilience. Additionally, medical educators must be aware of other, non-student factors that may impact student mental health, such as curriculum design and learning experience.