"Doctors on the move": Exploring professionalism in the light of cultural transitions

Incorporating equity, diversity and inclusion (EDI) into the education and assessment of professionalism for healthcare professionals and trainees: a scoping review

BACKGROUND

Current definitions of professionalism for healthcare trainees often lack equity, diversity and inclusion (EDI) in the expectations and assessment of professionalism. While professionalism teaching is incorporated in healthcare training, equity-deserving groups still experience discrimination. This scoping review investigates the literature to understand how EDI and associated domains of cultural humility, and advocacy can be incorporated in healthcare trainees' education and assessment of professionalism.

METHODS

The Arksey and O'Malley framework was applied to this scoping review. MEDLINE, Embase & PsychINFO were searched up to March 2023, with terms surrounding health professionals, professionalism, EDI, cultural humility, and advocacy. Titles and abstracts (n = 3870) and full-texts (n = 140) were independently screened by two reviewers. Articles were included if they focused on EDI, cultural humility, or advocacy among healthcare students/trainees, and had outcomes related to professionalism. Articles lacking discussion of professionalism as an outcome were excluded. Themes were generated by mutual discussion. Risk of bias was assessed using the Cote et al. and Medical Education Research Study Quality Instrument (MERSQI) tools.

RESULTS

48 articles underwent thematic analysis. Studies investigated the disciplines of medicine, nursing, social work, physiotherapy, and dentistry. Most studies were qualitative in methodology (n = 23). Three themes emerged: (1) EDI-related interventions are associated with improved professionalism of healthcare trainees/workers (n = 21). Interventions employed were either an EDI-associated educational course (n = 8) or an exchange program to promote EDI competencies among trainees (n = 13). (2) Trainee definitions and perceptions of professionalism include themes related to EDI and cultural humility (n = 12). (3) Current standards of professionalism are perceived as non-inclusive towards historically-marginalized populations (n = 15). Literature investigating advocacy as it relates to professionalism is limited.

CONCLUSION

This review identified that core EDI principles and its associated domains of cultural humility and advocacy are often viewed as integral to professionalism. These findings create a strong impetus to incorporate EDI principles within professionalism frameworks in healthcare education. Future research should employ standardized tools for professionalism assessment to provide more conclusive evidence. Incorporating patient perspectives of professionalism can inform actionable recommendations for fostering inclusive healthcare environments.

Gender Matters: Understanding Transitions in Surgical Education

Introduction

Diverse transitions are elemental to medical career trajectories. The effective navigation of such transitions influences a sense of belonging and wellbeing, positive relationships, and good engagement and attainment within new contexts. Using Multiple and Multidimensional Transitions (MMT) theory as an analytical lens, this paper aims to answer the research question: “What gendered transitions do female surgeons experience, and how do these gendered transitions impact them?”

Methods

We conducted a qualitative study drawing on narrative inquiry, with face-to-face and online semi-structured interviews with 29 female surgeons across nine surgical specialities in Ireland and Scotland. This paper is part of a larger study including male surgeons, other colleagues and patients of female surgeons. The female surgeons in this paper were purposively sampled using maximum variation sampling across several levels (consultants, trainees and middle-grade doctors), as well as six who had transitioned out of surgery. Framework analysis was employed to interrogate the interview data.

Results

Five overarching types of transitions were identified across surgical education but only three of these transitions—work, culture and health—were primarily experienced by female surgeons (not male surgeons so were considered gendered), thereby impacting social, academic, and psychological domains. The remaining two types of transition—education and geography—were seemingly experienced equally by female and male surgeons, so are beyond the scope of this paper focused on female surgeons’ gendered experiences.

Conclusion

This novel qualitative study drawing on MMT theory illustrates how multiple gendered transitions interact and impact female surgeons across the surgical education continuum. Aligned with MMT theory, family members and others are also purportedly affected by female surgeons’ transitions. Healthcare educators, leaders and policymakers need to better understand gendered transitions and their impacts to improve support for female surgical trainees on their educational journeys.

Conceptualising professionalism in dietetics: an Australasian qualitative study

BACKGROUND

Professionalism is a vital aspect of healthcare and multidisciplinary teamwork. While there is substantive professionalism literature in medicine and an expanding healthcare professions literature, there is a significant gap in understanding professionalism in dietetics. There are very few research papers in the dietetics literature on this issue compared with other health professions. Given the multidisciplinary nature of healthcare, it is important to understand what professionalism means within each profession to develop shared understandings across healthcare teams.

OBJECTIVE

The study aim was to explore how dietetics professionalism is conceptualised by dietetic practitioners/preceptors, faculty and new graduates.

DESIGN

A constructionist exploratory qualitative interview study was conducted.

PARTICIPANTS/SETTING

One hundred participants (dietetic graduates, faculty and practitioners/preceptors), associated with 17 universities across Australia and New Zealand and from diverse geographical and work settings, participated in 27 group and 24 individual interviews from March 2018 to June 2019.

ANALYSIS PERFORMED

Thematic framework analysis was used to examine participants' understandings of professionalism.

RESULTS

Twenty-three dimensions of dietetics professionalism were identified, with the most common being communication and including four novel dimensions of professionalism (generational, emotion management, cultural capability and advocacy) not previously described in other professions. Professionalism as emotion management and generational adds new insights to the professionalism literature, expanding understandings of this vital aspect of healthcare. While high levels of consistency in professionalism understandings existed across the three stakeholder groups, some interesting differences were found. The profession of dietetics shares similarities with other professions in the ways professionalism is conceptualised.

CONCLUSIONS

Using these dimensions of professionalism as a framework for teaching and learning about professionalism will help in clarifying expectations and expand shared understandings about professionalism for dietitians, other health professions and across multidisciplinary teams.

Long-term contribution of international electives for medical students to professional identity formation: a qualitative study

OBJECTIVES

Globalisation has given medical university students the opportunity to pursue international electives in other countries, enhancing the long-term socialisation of medical professionals. This study identified the long-term effects of international electives on the professional identity formation of medical students.

DESIGN

This is a qualitative study.

SETTING

The authors interviewed Japanese medical professionals who had completed their international electives more than 10 years ago, and analysed and interpreted the data using a social constructivism paradigm.

PARTICIPANTS

A total of 23 medical professionals (mean age 36.4 years; range 33-42 years) participated in face-to-face, semistructured in-depth interviews.

RESULTS

During the data analysis, 36 themes related to professional identity formation were identified, and the resulting themes had five primary factors (perspective transformation, career design, self-development, diversity of values and leadership). It was concluded that international electives for medical students could promote reflective self-relativisation and contribute to medical professional identity formation. Additionally, such electives can encourage pursuing a specialisation and academic or non-academic work abroad. International electives for medical students could contribute to medical professional identity formation on the basis of cross-cultural understanding.

CONCLUSIONS

This study addressed a number of issues regarding the long-term impact of international elective experiences in various countries on the professional identity formation of Japanese medical professionals. This study offers some guidance to mentors conducting international electives and provides useful information for professional identity formation development in medical professionals.

Professional decision-making in medicine: Development of a new measure and preliminary evidence of validity

Introduction

This study developed a new Professional Decision-Making in Medicine Measure that assesses the use of effective decision-making strategies: seek help, manage emotions, recognize consequences and rules, and test assumptions and motives. The aim was to develop a content valid measure and obtain initial evidence for construct validity so that the measure could be used in future research or educational assessment.

Methods

Clinical scenario-based items were developed based on a review of the literature and interviews with physicians. For each item, respondents are tasked with selecting two responses (out of six plausible options) that they would choose in that situation. Three of the six options reflect a decision-making strategy; these responses are scored as correct. Data were collected from a sample of 318 fourth-year medical students in the United States. They completed a 16-item version of the measure (Form A) and measures of social desirability, moral disengagement, and professionalism attitudes. Professionalism ratings from clerkships were also obtained. A sub-group (n = 63) completed a second 16-item measure (Form B) to pilot test the instrument, as two test forms are useful for pre-posttest designs.

Results

Scores on the new measure indicated that, on average, participants answered 75% of items correctly. Evidence for construct validity included the lack of correlation between scores on the measure and socially desirable responding, negative correlation with moral disengagement, and modest to low correlations with professionalism attitudes. A positive correlation was observed with a clerkship rating focused on professionalism in peer interactions.

Conclusions

These findings demonstrate modest proficiency in the use of decision-making strategies among fourth-year medical students. Additional research using the Professional Decision-Making Measure should explore scores among physicians in various career stages, and the causes and correlates of scores. Educators could utilize the measure to assess courses that teach decision-making strategies.

Exploring medical leader identity and its formation

PURPOSE

"Becoming" a doctor involves the acquisition of medical knowledge, skills and professional identity. Medical professional identity formation (MPIF) is complex, multi-factorial and closely linked to societal expectations, personal and social identity. Increasingly, doctors are required to engage in leadership/management involving significant identity shift. This paper aims to explore medical professional identity (MPI) and MPIF in relation to doctors as leaders. Selected identity theories are used to enrich the understanding of challenges facing doctors in leadership situations and two concepts are introduced: medical leader identity (MLI) and medical leader identity formation (MLIF) and consideration given to how they can be nurtured within medical practice.

DESIGN/METHODOLOGY/APPROACH

A rapid conceptual review of relevant literature was carried out to identify a set of relevant concepts and theories that could be used to develop a new conceptual framework for MLI and MLIF.

FINDINGS

MLIF is crucial for doctors to develop as medical leaders, and, like MPIF, the process begins before medical school with both identities influenced, shaped and challenged throughout doctors' careers. Individuals require support in developing awareness that their identities are multiple, nested, interconnected and change over time.

ORIGINALITY/VALUE

This paper draws on concepts from wider literature on professional identity, in relation to how doctors might develop their MLI alongside their MPI. It offers a new perspective on MPI in the light of calls on doctors to "become and be healthcare leaders" and introduces the new concepts of MLI and MLIF.

Inclusive and person-centred leadership: creating a culture that involves everyone

Contemporary leadership theory is based on the dynamic processes that occur between leaders and followers. One such theory is inclusive leadership, which is a person-centred approach that focuses on the empowerment and development of followers. It has roots in other leadership theories such as transformational leadership, but there are distinguishing features. This review discusses these features and presents a case study. Inclusive leadership is also viewed in the context of diversity, organizational culture and innovation. This is then further explored in regards to the diverse workforce of the NHS, with particular focus on the black and minority ethnic groups.

Applications of the reflective practice questionnaire in medical education

BACKGROUND

We sought to determine whether the Reflective Practice Questionnaire (RPQ) is a reliable measure of reflective capacity and related characteristics in medical students. We also planned to learn how the RPQ could be used in medical education.

METHODS

The RPQ is a 40 item self-report questionnaire that includes a multi-faceted approach to measuring reflective capacity. It also includes sub-scales on several other theoretically relevant constructs such as desire for improvement, confidence, stress, and job satisfaction. The reliabilities of reflective capacity and other sub-scales were determined by calculating their Cronbach alpha reliability values. In the present study, the RPQ was answered by 98 graduating fourth-year medical students from an American University, and these RPQ scores were compared with general public and mental health practitioner samples from a prior study using ANOVA and Bonferroni adjusted comparisons.

RESULTS

Medical students reported a higher reflective capacity than the general public sample, but students were statistically indistinguishable from the mental health practitioner sample. For medical students, reflective capacity was associated with features of confidence, stress, and desire for improvement. Job satisfaction was positively associated with confidence in communication with patients, and negatively associated with stress when interacting with patients. A cluster analysis revealed that around 19% of the medical students exhibited a relatively high level of anxiety interacting with patients, 23% were less engaged, 5% were dissatisfied, and 7% expressed a level of over-confidence in their knowledge and skills that was concerning.

CONCLUSIONS

The RPQ is a reliable measure of reflective capacity (Chronbach's alpha value = 0.84) and related characteristics (Cronbach's alpha values from 0.75 to 0.83) in medical students. The RPQ can be used as part of pre-post evaluations of medical education initiatives, to complement student self-reflection activities in the curriculum, and to identify students who might benefit from targeted intervention.

Internationally educated nurses' and medical graduates' experiences of getting a license and practicing in Sweden - a qualitative interview study

BACKGROUND

The Swedish healthcare system has an increased need for nurses and physicians, and the number of International Educated Nurses (IENs) and International Medical Graduates (IMGs) seeking job opportunities and a license to practice in Sweden is rising. This study explored how IENs and IMGs describe their experience of getting a license to practice, their perceptions of working in Sweden and of how their intercultural competence is utilized.

METHOD

A qualitative study based on semi-structured interviews with 11 IENs and 11 IMGs. The interviews were conducted between 2015 and 2017. The data were analyzed using qualitative content analysis.

RESULTS

Three main themes were identified: 'Getting a license - a different story,' 'The work is familiar, yet a lot is new,' 'Trying to master a new language.' The time to obtain a license to practice and finding a job was shorter for IENs and IMGs coming from European countries than for those from non-European countries. Some of the experiences of getting a license to practice and of entering a new workplace in another country were the same for nurses and physicians. In general, both IENs and IMGs felt welcomed and used their intercultural competence at work. Lack of language skills was regarded as the main problem for both professions, while workplace introduction was shorter for IMGs than for IENs.

CONCLUSIONS

Problems related to language and culture are often underestimated, therefore organizations and managers employing IENs and IMGs should provide longer workplace introduction to facilitate the acculturation process. More time-efficient language courses specifically adapted to IENs and IMGs could make the transition easier and shorten the time to obtain a license to practice for both professions.

Twelve tips for integrating leadership development into undergraduate medical education

Healthcare systems need effective leadership. All healthcare professionals can and should "learn to lead" and this requires a clear focus on leadership development from the earliest stages of a career. Within medicine, undergraduate students should be provided with opportunities to thrive and develop their skills in terms of leadership, management and followership. Drawing from the existing evidence base, the authors' expertise and the latest "thought leadership", these 12 tips provide practical guidance to universities and associated provider organizations, and to academic and clinical faculty, on how to integrate leadership development into their undergraduate medical programs. These 12 tips will help educators provide medical education that incorporates leadership as a core part of a professional's identity, and help students gain a deeper understanding of themselves and the teams, organizations and system they work within.

Becoming a Doctor in Different Cultures: Toward a Cross-Cultural Approach to Supporting Professional Identity Formation in Medicine

Becoming a doctor is fundamentally about developing a new, professional identity as a physician, which in and of itself may evoke many emotions. Additionally, medical trainees are increasingly moving from one cultural context to another and are challenged with navigating the resulting shifts in their professional identify. In this Article, the authors aim to address medical professional identity formation from a polyvocal, multidisciplinary, cross-cultural perspective. They delineate the cultural approaches to medical professionalism, reflect on professional identity formation in different cultures and on different theories of identity development, and advocate for a context-specific approach to professional identity formation. In doing so, the authors aim to broaden the developing professional identity formation discourse to include non-Western approaches and notions.

A fresh look at Miller's pyramid: assessment at the 'Is' and 'Do' levels

In its silver jubilee, we celebrate the ground-breaking pyramid of George Miller by submitting a fresh look at it. We discuss two questions. (i) Does the classical pyramidal structure perfectly portray the relationships of the four levels that were described by Miller? (ii) Can the model of Miller fulfill the unmet needs of assessors to measure evolving essential constructs and accommodate the increasingly sophisticated practice of assessment of health professionals? In response to the first question, Miller's pyramid is revisited in view of two assumptions for pyramidal structures, namely: hierarchy and tapering. Then we suggest different configurations for the same classical four levels and indicate when to use each one. With regard to the second question, we provide a rationale for amending the pyramid with two further dimensions to assess personal qualities of students at the 'Is' level and their performance in teams at the 'Do' (together) level. At the end of the article, we yearn to think outside the pyramid and suggest the Assessment Orbits framework to assess students as individuals and in teams. The five Assessment Orbits alert educators to assess the emerging cognitive and non-cognitive constructs, without implying features such as hierarchy or tapering that are ingrained in pyramidal structures. The 'Is' orbit attends to the personal qualities of graduates 'who' we may (or may not) trust to be our physicians. Assessment of teams at the 'Do' level (together) offers a paradigm shift in assessment from competitive ranking (storming) among students toward norming and performing as teams.