International medical graduates' experiences with caring for cross-cultural patient populations: Qualitative study in Alberta

OBJECTIVE

To explore experiences of international medical graduate (IMG) FPs in providing cross-cultural patient care and to identify rewards and challenges they experienced when caring for patients of cultural backgrounds different from their own.

DESIGN

Descriptive qualitative study.

SETTING

Family medicine primary care practices in Alberta.

PARTICIPANTS

Eighteen IMG FPs practising in the metropolitan areas of Edmonton or Calgary in Alberta as of May 2013.

METHODS

Individual face-to-face or telephone interviews were conducted using a semistructured interview guide. Seventeen interviews occurred between July and August 2013 and 1 took place in August 2014. All interviews were audiorecorded and transcribed verbatim. Transcribed data were subject to thematic analysis.

MAIN FINDINGS

International medical graduates identified several rewarding aspects of caring for patients with cultural backgrounds different from their own, including learning about different cultures, perceiving that appointments are more succinct, and advocating for patients whom they perceive to be at a disadvantage. Family physicians also identified several challenges associated with caring for patients of different cultural backgrounds, including encountering language barriers, perceiving that visits take longer, and experiencing patients' lack of acceptance of FPs with cultural backgrounds different from their own.

CONCLUSION

Cultural differences between FPs and patients can enhance or undermine doctor-patient relationships. The results of this study speak to the need for cultural competency training for FPs practising in culturally diverse settings.

What about Happiness? A Critical Narrative Review with Implications for Medical Education

Introduction

Despite abundant scholarship and improvement initiatives, the problem of physician wellbeing persists. One reason might be conceptual: the idea of 'happiness' is rare in this work. To explore how it might influence the conversation about physician wellbeing in medical education, we conducted a critical narrative review asking: 'How does happiness feature in the medical education literature on physician wellbeing at work?' and 'How is happiness conceptualized outside medicine?'

Methods

Following current methodological standards for critical narrative review as well as the Scale for the Assessment of Narrative Review Articles, we conducted a structured search in health research, humanities and social sciences, a grey literature search, and consultation with experts. After screening and selection, content analysis was performed.

Results

Of 401 identified records, 23 were included. Concepts of happiness from the fields of psychology (flow, synthetic happiness, mindfulness, flourishing), organizational behaviour (job satisfaction, happy-productive worker thesis, engagement), economics (happiness industry, status treadmill), and sociology (contentment, tyranny of positivity, coercive happiness) were identified. The medical education records exclusively drew on psychological concepts of happiness.

Discussion and Conclusion

This critical narrative review introduces a variety of conceptualizations of happiness from diverse disciplinary origins. Only four medical education papers were identified, all drawing from positive psychology which orients us to treat happiness as individual, objective, and necessarily good. This may constrain both our understanding of the problem of physician wellbeing and our imagined solutions. Organizational, economical and sociological conceptualizations of happiness can usefully expand the conversation about physician wellbeing at work.

Documentation as composing: how medical students and residents use writing to think and learn

Some educators have described clinical documentation as "scut". Research in medicine has focused on documentation's communicative value and not its function in learning. With time being an important commodity and electronic health records changing how we document, understanding the learning value of documentation is essential. The purpose of this study was to explore how trainee composing practices shape learning. Qualitative methods employing Rhetorical Genre Theory were used to explore clinical documentation practices among medical trainees. Data collection and analysis occurred in iterative cycles. Data included field notes and field interviews from 110 h of observing junior trainees and senior internal medicine residents participating in patient admission and follow-up visits. Analysis was focused on Paré and Smart's framework for studying documentation as composing. From a composing lens, documentation plays a vital role in learning in clinical settings. Junior trainees were observed to be reliant on using writing to support their thinking around patient care. Before patient encounters, writing helped trainees focus on what was already known and develop a preliminary understanding of the patient's problem(s). After encounters, writing helped trainees synthesize the data and develop an assessment and plan. Before and after the encounter, through writing, trainees also identified knowledge and data collection gaps. Our findings highlight clinical documentation as more than a communication task. Rather, the writing process itself appeared to play a pivotal role in supporting thinking. While some have proposed strategies for reducing trainee involvement, we argue that writing can be time well spent.

"Influential" Intraoperative Educators and Variability of Teaching Styles

OBJECTIVES

Academic surgeons manage their role as intraoperative educators in a variety of ways. Such variability is neither idiosyncratic nor is there a single best approach. This study sought to explore the practices of surgeons deemed influential by their residents, allowing insight into a variety of potentially effective practices.

PARTICIPANTS

Constructivist grounded theory guided data collection and analysis. Data sources included surveys from senior surgical residents (PGY3-6) and recent graduates from an academic hospital in Canada (36% response rate), intraoperative observations of teaching interactions, and semi-structured interviews with observed surgeons. Rigour was supported by data triangulation, constant comparison, and collection to theoretical sufficiency.

DESIGN

We developed a framework grouping effective teaching into three overlapping approaches: exacting, empowering, and fostering. The approaches differ based on the level of independence granted and the degree of expectation placed on individual residents. Each demonstrates different strategies for balancing the multiple supervisory roles and patient care obligations faced by academic surgeons. We also identified strategies that could be used across approaches to enhance learning.

CONCLUSIONS

For surgical educators seeking to improve upon the quality of the intraoperative supervision they provide, frameworks such as this may serve as models of effective supervision. Enhancing surgeons' knowledge of proven strategies, combined with reflecting on how they teach and how they balance responsibilities to patients and trainees, may allow them to broaden their educational practice.

Exploring medical students' perspectives of physician leadership

BACKGROUND

Leadership has been recognized as an important competency in medicine. Nevertheless, leadership curricula for Canadian medical students lacks standardization and may not be informed by medical students' perspectives of physician leadership. The purpose of this study was to elicit these perspectives on physician leadership.

METHODS

The present study utilized semi-structured interviews to ascertain the views of medical student participants, including students in their first, second and third years of medical school, on physician leadership. Interview questions were based on 'the 3-C model' of physician leadership, which includes three aspects of leadership, namely character, competence and commitment. The interviews were audio-recorded, transcribed and then coded using thematic analysis.

RESULTS

The medical students of this study provided rich examples of resident and staff physicians demonstrating effective and ineffective leadership. The participants identified the importance of character to effective physician leadership, but some participants also described a feeling of disconnect with the relevance of character at their stage of training. When discussing physician competence, medical students described the importance of both medical expertise and transferable skills. Lastly, the leadership aspect of commitment was identified as being relevant, but medical students cautioned against the potential for physician burnout. The medical student participants' suggestions for improved leadership development included increased experiences with examples of physician leadership, opportunities to engage in leadership and participation in reflection exercises.

CONCLUSIONS

Overall, the study participants demonstrated an appreciation for three aspects of leadership; character, competence and commitment. Furthermore, they also provided recommendations for the future design of medical leadership curricula.

An Approach to Leadership Development and Patient Safety and Quality Improvement Education in the Context of Professional Identity Formation in Pre-Clinical Medical Students

Objectives

Leadership and patient safety and quality improvement (PSQI) are recognized as essential parts of a physician's role and identity, which are important for residency training. Providing adequate opportunities for undergraduate medical students to learn skills related to these areas, and their importance, is challenging.

Methods

The Western University Professional Identity Course (WUPIC) was introduced to develop leadership and PSQI skills in second-year medical students while also aiming to instill these topics into their identities. The experiential learning portion was a series of student-led and physician-mentored PSQI projects in clinical settings that synthesized leadership and PSQI principles. Course evaluation was done through pre/post-student surveys and physician mentor semi-structured interviews.

Results

A total of 108 of 188 medical students (57.4%), and 11 mentors (20.7%), participated in the course evaluation. Student surveys and mentor interviews illustrated improved student ability to work in teams, self-lead, and engage in systems-level thinking through the course. Students improved their PSQI knowledge and comfort levels while also appreciating its importance.

Conclusion

The findings from our study suggest that undergraduate medical students can be provided with an enriching leadership and PSQI experience through the implementation of faculty-mentored but student-led groups at the core of the curricular intervention. As students enter their clinical years, their first-hand PSQI experience will serve them well in increasing their capacity and confidence to take on leadership roles.

From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

Discharging the complex patient - changing our focus to patients' networks of care providers

Background

A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning.

Methods

This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical.

Results

We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial.

Conclusions

Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06841-2.

Factors perceived to influence rural career choice of urban background family physicians: A qualitative analysis

BACKGROUND

Urban background physicians are the main source of physician supply for rural communities across Canada. The purpose of this study was to describe factors that are perceived to influence rural career choice and practice location of urban background family medicine graduates.

METHODS

We conducted a qualitative, descriptive study employing telephone interviews with 9 urban background family physicians practicing in rural locations. Those who completed residency training between 2006 and 2011, were in rural practice, and had an urban upbringing were asked: when the decision for rural practice was made; factors that influenced rural career choice; and factors that influenced choice of a particular rural location. Emerging themes were identified through content analysis of interview data.

RESULTS

We identified four themes as factors perceived to influence rural career choice - variety/broad scope of rural practice, rural lifestyle, personal relationships, and positive rural experience/physician role models. We also identified factors in four areas perceived to influence the choice of a particular rural practice location - having lived in the rural community, spousal influence, personal lifestyle, and comfort with practice expectations.

CONCLUSION

Decisions for rural career choice and rural practice location by practicing urban background family medicine graduates are based on clinical practice considerations, training experience, as well as personal and lifestyle factors.

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care

PURPOSE

The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams.

METHOD

Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis.

RESULTS

The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover).

CONCLUSIONS

Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

Leadership Development in Postgraduate Medical Education: A Systematic Review of the Literature

PURPOSE

To evaluate and interpret evidence relevant to leadership curricula in postgraduate medical education (PGME) to better understand leadership development in residency training.

METHOD

The authors conducted a systematic review of peer-reviewed, English-language articles from four databases published between 1980 and May 2, 2017 that describe specific interventions aimed at leadership development. They characterized the educational setting, curricular format, learner level, instructor type, pedagogical methods, conceptual leadership framework (including intervention domain), and evaluation outcomes. They used Kirkpatrick effectiveness scores and Best Evidence in Medical Education (BEME) Quality of Evidence scores to assess the quality of the interventions.

RESULTS

Twenty-one articles met inclusion criteria. The classroom setting was the most common educational setting (described in 17 articles). Most curricula (described in 13 articles) were isolated, with all curricula ranging from three hours to five years. The most common instructor type was clinical faculty (13 articles). The most commonly used pedagogical method was small group/discussion, followed by didactic teaching (described in, respectively, 15 and 14 articles). Study authors evaluated both pre/post surveys of participant perceptions (n = 7) and just postintervention surveys (n = 10). The average Kirkpatrick Effectiveness score was 1.0. The average BEME Quality of Evidence score was 2.

CONCLUSIONS

The results revealed that interventions for developing leadership during PGME lack grounding conceptual leadership frameworks, provide poor evaluation outcomes, and focus primarily on cognitive leadership domains. Medical educators should design future leadership interventions grounded in established conceptual frameworks and pursue a comprehensive approach that includes character development and emotional intelligence.

Supporting Family Caregivers of Seniors Within Acute and Continuing Care Systems

BACKGROUND

Family caregivers who provide care to seniors at no cost to the healthcare system are an integral part of the healthcare system. Caregiving, however, can cause significant emotional, physical and financial burden. We held a one-day symposium on how to best involve and support family caregivers in the healthcare system. The symposium brought together caregivers, healthcare providers, administrators and policy-makers to identify needs and make recommendations to address these issues.

METHODS

Participants engaged in conversation circles which were audio-recorded and transcribed. Data were qualitatively analyzed alongside written notes provided by participants.

RESULTS

Symposium participants identified a lack of both orientation and education for healthcare providers about family caregivers and standardized processes for assessing caregiver burden. They highlighted a need to ensure that the family experience is captured and included as an essential component of care, foster a culture of collaboration, expand the notion of the healthcare team to include family caregivers, provide more integrated palliative care, and enhance policies and programs to acknowledge family caregivers.

CONCLUSION

There is a need to recognize the essential role of family caregivers in seniors' health and well-being, and to take on a more comprehensive approach to patient care.

The 5As team patient study: patient perspectives on the role of primary care in obesity management

Background

Over 60% of people have overweight or obesity, but only a third report receiving counselling from primary care providers. We explored patients’ perspectives on the role of primary care in obesity management and their experience with existing resources, with a view to develop an improved understanding of this perspective, and more effective management strategies.

Methods

Qualitative study employing semi-structured interviews and thematic analysis, with a sample of 28 patients from a cohort of 255 patients living with obesity and receiving care to support their weight management in a large Primary Care Network of family practices in Alberta.

Results

Four illustrative themes emerged: (1) the patient-physician relationship plays an important role in the adequacy of obesity management; (2) patients have clear expectations of substantive conversations with their primary care team; (3) complex conditions affect weight and patients require assistance tailored to individual obesity drivers; (4) current services provide support in important ways (accessibility, availability, accountability, affordability, consistency of messaging), but are not yet meeting patient needs for individual plans, advanced education, and follow-up opportunities.

Conclusions

Patients have clear expectations that their primary care physician asks them about weight within a supportive therapeutic relationship. They see obesity as a complex phenomenon with multiple drivers. They want their healthcare providers to assess and address their root causes - not simplistic advice to “eat less, move more”. Patients felt that the current services were positive resources, but expressed needs for tailored weight management plans, and longer-term follow-up.