An Insight into Professional Identity Formation: Qualitative Analyses of Two Reflection Interventions During the Dissection Course

The professional behavior of future doctors is increasingly important in medical education. One of the first subjects in the curriculum to address this issue is gross anatomy. The Tuebingen Medical Faculty implemented a learning portfolio and a seminar on medical professionalism during the dissection course. The aims of this research project are to get an overview of how students form a professional identity in the dissection course and to compare the content of both their oral and written reflections on the course. A qualitative analysis was conducted of the oral and written reflections on the dissection laboratory experience. This study was conducted during winter term 2013/2014 with a cohort of 163 participants in the regular dissection course. Written reflection texts (from n = 96 students) and audio recordings from four oral reflection seminar discussions (with n = 11 students) were transcribed and deductively categorized with Mayring's qualitative content analysis method. Both qualitative analyses show that students reflected on many topics relevant to professional development, including empathy, respect, altruism, compassion, teamwork, and self-regulation. Quantitative analysis reveals that students who attended the oral reflection wrote significantly more in their written reflection than students who did not. There is, however, no difference in the reflection categories. Reflection content from students corresponds with categories derived from existing competency frameworks. Both the seminar (oral reflections) and the learning portfolio (written reflections) present excellent opportunities to foster professional development during anatomy education; the key is using them in conjunction with the dissection course.

The ecology of pneumocystis: perspectives, personal recollections, and future research opportunities

I am honored to receive the second Lifetime Achievement Award by International Workshops on Opportunistic Protists and to give this lecture. My research involves Pneumocystis, an opportunistic pulmonary fungus that is a major cause of pneumonia ("PcP") in the immunocompromised host. I decided to focus on Pneumocystis ecology here because it has not attracted much interest. Pneumocystis infection is acquired by inhalation, and the cyst stage appears to be the infective form. Several fungal lung infections, such as coccidiomycosis, are not communicable, but occur by inhaling < 5 μm spores from environmental sources (buildings, parks), and can be affected by environmental factors. PcP risk factors include environmental constituents (temperature, humidity, SO2 , CO) and outdoor activities (camping). Clusters of PcP have occurred, but no environmental source has been found. Pneumocystis is communicable and outbreaks of PcP, especially in renal transplant patients, are an ongoing problem. Recent evidence suggests that most viable Pneumocystis organisms detected in the air are confined to a patient's room. Further efforts are needed to define the risk of Pneumocystis transmission in health care facilities; to develop more robust preventive measures; and to characterize the effects of climatological and air pollutant factors on Pneumocystis transmission in animal models similar to those used for respiratory viruses.

How to achieve synergy between medical education and cognitive neuroscience? An exercise on prior knowledge in understanding

A major challenge in contemporary research is how to connect medical education and cognitive neuroscience and achieve synergy between these domains. Based on this starting point we discuss how this may result in a common language about learning, more educationally focused scientific inquiry, and multidisciplinary research projects. As the topic of prior knowledge in understanding plays a strategic role in both medical education and cognitive neuroscience it is used as a central element in our discussion. A critical condition for the acquisition of new knowledge is the existence of prior knowledge, which can be built in a mental model or schema. Formation of schemas is a central event in student-centered active learning, by which mental models are constructed and reconstructed. These theoretical considerations from cognitive psychology foster scientific discussions that may lead to salient issues and questions for research with cognitive neuroscience. Cognitive neuroscience attempts to understand how knowledge, insight and experience are established in the brain and to clarify their neural correlates. Recently, evidence has been obtained that new information processed by the hippocampus can be consolidated into a stable, neocortical network more rapidly if this new information fits readily into a schema. Opportunities for medical education and medical education research can be created in a fruitful dialogue within an educational multidisciplinary platform. In this synergetic setting many questions can be raised by educational scholars interested in evidence-based education that may be highly relevant for integrative research and the further development of medical education.

MR and applanation tonometry derived aortic impedance: association with aging and left ventricular remodeling

PURPOSE

We sought to noninvasively estimate aortic impedance indices from MR and tonometric data.

MATERIALS AND METHODS

MR aortic velocity-encoded and carotid applanation tonometry pressure data of 70 healthy subjects (19-79 years) were used to calculate the following indices from impedance spectrum: (i) characteristic impedance (Zc) reflecting pulsatile component of left ventricular (LV) afterload, (ii) frequency of the minimal impedance magnitude related to arterial compliance (FMIN ), (iii) total peripheral resistance (TPR) related to steady LV load, (iv) impedance oscillatory index (ZINDEX ) related to proximal reflections, and (v) reflection magnitude (RM). Associations with age and LV remodeling (LV mass/end-diastolic volume) were investigated using multivariate analysis.

RESULTS

All indices except Zc were associated with age independent of subjects characteristics and systolic blood pressures. They were all significantly associated with the well-established carotid-femoral pulse wave velocity (r ≥ 0.29; P < 0.01). However, such associations were not independent of age. Pulsatile index Zc was independently associated with carotid pulse pressure (r = 0.53, P < 0.001). Moreover, conversely to conventional stiffness indices, Zc and TPR were independently associated with LV remodeling (r = 0.30, r = 0.43, respectively, P < 0.01).

CONCLUSION

We estimated aortic impedance from velocity-encoded MR and tonometry data resulting in reliable impedance and reflection indices as confirmed by their significant and independent associations with age and LV remodeling.

Walking through life with cerebral palsy: reflections on daily walking by adults with cerebral palsy

Purpose: Walking is a major target in childhood physiotherapy for children with cerebral palsy (CP). Little information exists on the importance or value of walking when these children grow up. The aim of this study was to explore personal reflections on daily walking by adults with CP.

Method: Semi-structured individual interviews were conducted and analysed with systematic text condensation, a four-step thematic cross-case analysis.

Results: Eight ambulatory adults (26–60 years, four women and four men) with CP were interviewed. Almost all had experienced deteriorated walking ability in adulthood and reported that walking was restricted and affected by intrinsic features, such as pain, fatigue, reduced balance and fear of falling. Extrinsic features such as being looked at due to walking abnormality and environmental factors, such as seasonal changes affected their free walking and was common. Some had accepted using mobility aids for energy conservation.

Conclusions: Both intrinsic and extrinsic factors influence walking in adults with CP. Reflections by the adults with CP suggest these features may reduce participation in public spaces and potentially increase acceptance and use of mobility aids.

Life After Being a Pathology Department Chair III: Reflections on the "Afterlife"

The Association of Pathology Chairs Senior Fellows Group provided reflections on activities that have kept them engaged and inspired after stepping down as chair. They offered advice to current chairs who were considering leaving their positions and also to individuals contemplating becoming pathology chairs. A majority (35/41) responded: 60% maintained teaching/mentoring activities; 43% engaged in hobbies; 40% took other administrative positions including deans, medical center chief executive officers, and residency program directors; 31% continued research; 28% wrote books; 20% performed community service; 14% led professional organizations; 14% developed specialized programs; 11% engaged in clinical service; and 11% performed entrepreneurial activities. Most individuals had several of these activities. One-third indicated that those considering becoming chair should be able to place faculty and department needs before their own. One-fourth emphasized the need to know why one wants to become chair, the need to develop clear goals, and the need to know what one wants to accomplish as chair before applying for and accepting the position. More than half (57%) indicated that before stepping down as chair, one should have a clear plan and/or professional goals that can be served by stepping down. Some even suggested that this be in place before applying for the chair. Almost two-thirds (63%) indicated they had no regrets stepping down as chair. These findings may be valuable to those contemplating stepping down from or stepping into any department chair position or other academic leadership role.

Reflections on 30 years of Cognition & Emotion

The publication of the first issue of Cognition & Emotion in 1987 helped open the floodgates to what has become a golden age of emotion research in the social and biological sciences. In this article, I describe the intellectual landscape of that era and trace key developments that helped foster the growth of the field of affective science. Looking back from a present-day perspective, I offer some thoughts on the major changes that have occurred over the past three decades, the opportunities and challenges that lie ahead, and my own personal journey toward becoming an affective scientist (which largely occurred during this period). Finally, I offer three considerations that might be helpful for young researchers who are already in the field of affective science or are considering entering it.

Early hearing detection and intervention: Reflections from the South African context

For researchers and clinicians in developing contexts like South Africa, the establishment of universal newborn hearing screening (UNHS) programmes is something which we have strived to achieve. However, we need to ask the question as to whether we have attempted to view our ultimate goal of achieving mandated UNHS programmes from the perspective of the South African healthcare system as a whole. The current manuscript is aimed at providing an overview of audiological services within a broader context, with reflections from a South African perspective, and a suggestion to consider alternatives to UNHS, particularly in the South African public health care sector.

The next major emergent infectious disease: reflections on vaccine emergency development strategies

INTRODUCTION

Major emergent infectious diseases (MEID) pose the most serious threat to human health. The research proposes targeted response strategies for the prevention and control of potential MEID.

AREAS COVERED

Based on the analysis of infectious diseases, this research analyzes pandemics that have a high probability of occurrence and aims to synthesize the past experience and lessons learned of controlling infectious diseases such as coronavirus, influenza, Ebola, etc. In addition, by integrating major infectious disease response guidelines developed by WHO, the European Union, the United States, and the United Kingdom, we intend to bring forward national vaccine R&D development strategies for emergency use.

EXPERT OPINION

We advise to establish and improve existing laws, regulations, and also prevention and control systems for the emergent R&D and application of vaccines in response to potential infectious diseases. The strategies would not only help increase the various abilities in response to the research, development, evaluation, production, and supervision of emergency vaccines, but also establish surrogate endpoint of immunogenicity protection in early clinical studies to enable a rapid evaluation of the efficacy of emergency vaccines.

Voluntary community service in medical school: a qualitative study on obstacles faced by student leaders and potential solutions

Purpose

In medical school, students may participate in various community involvement projects (CIP), which serve disadvantaged communities. However, several obstacles may arise during these projects. The authors conducted a qualitative study with the primary aim of understanding the obstacles and corresponding potential solutions when medical students in Singapore participate in local CIP (LCIP) and overseas CIP (OCIP).

Design

The authors recruited medical students from Yong Loo Lin School of Medicine, National University of Singapore, who were also leaders of a specific community service project done in medical school. Twelve one-to-one interviews were held for the participants from 6 to 8 January 2013. Participants were led in a discussion based on an interview guide. The interviews were audio-recorded and transcribed into free-flow text. Subsequently, content and thematic analyses of the transcripts were performed independently by three researchers.

Results

The medical students faced many common obstacles during their community service projects. These obstacles include difficulties in recruiting and managing volunteers, attaining recognition or credibility for the project to acquire funding and resources, adjusting to a different culture or language, setting goals, and facing project-specific obstacles. Potential solutions were offered for some obstacles, such as building a strong executive committee for the project, grooming successive batches of leaders, and improving the project's public image, mentorship, reflections, and sustainability plans.

Conclusions

Mentorship, reflections, and sustainability are potential solutions that have been proposed to tackle the obstacles faced during community service participation in medical school. However, there may still be difficulty in solving some of the problems even after these measures are put into practice. Future research may focus on evaluating the effectiveness of these suggested solutions.

A district nurse's reflection on pre-registration nursing education: a troubling position

This article explores the author's observations as a qualified district nurse and senior lecturer in pre-registration nurse education. Perceived 'troubling' reflections suggest pre-registration nurse education appears very hospital focussed. Additionally, the role of the district nurse has become synonymous with the term 'community nurse', hiding the historical specialism it represents. Media representations of the term 'frontline' was particularly noted in relation to COVID-19, suggesting a heroism of nursing that only happened in hospital. More discussion will take place around how nursing is viewed within education by students, such as what we do to patients (catheterisation, blood sugars etc) rather than how we can work with them. All these areas appear to strengthen lingering historical myths around district nursing and student perceptions of this specialist profession.

Reflections on the development of medical informatics

The recording of numbers appears to pre-date the emergence of writing and excavations of the clay tablets of civilisations in the Middle East have shown that clay tablets were used to keep account of activities undertaken in a systematic fashion. Correspondingly, various forms of abacus have been used types of calculation from the Sumerian abacus dating from about 4 ½ thousand years ago to the Chinese abacus (Suanpan) from around 2 thousand years ago. As time passed various forms of writing were developed using animal hides, which were developed as vellum and papyrus which eventually developed into paper. Wood block printing, also, was a very ancient art and movable type printing had been utilised in the far East but the development of movable type page setting in Europe transformed the process of printing.

Measurement and Prediction of Binaural-Temporal Integration of Speech Reflections

For speech intelligibility in rooms, the temporal integration of speech reflections is typically modeled by separating the room impulse response (RIR) into an early (assumed beneficial for speech intelligibility) and a late part (assumed detrimental). This concept was challenged in this study by employing binaural RIRs with systematically varied interaural phase differences (IPDs) and amplitude of the direct sound and a variable number of reflections delayed by up to 200 ms. Speech recognition thresholds in stationary noise were measured in normal-hearing listeners for 86 conditions. The data showed that direct sound and one or several early speech reflections could be perfectly integrated when they had the same IPD. Early reflections with the same IPD as the noise (but not as the direct sound) could not be perfectly integrated with the direct sound. All conditions in which the dominant speech information was within the early RIR components could be well predicted by a binaural speech intelligibility model using classic early/late separation. In contrast, when amplitude or IPD favored late RIR components, listeners appeared to be capable of focusing on these components rather than on the precedent direct sound. This could not be modeled by an early/late separation window but required a temporal integration window that can be flexibly shifted along the RIR.

Experiences of Conducting Research With Vulnerable and Disempowered Participants in a Developing Country: Perspectives From a Novice Researcher

Sensitive, emotionally laden research requires mental strength, emotional fortitude, and logistic supports for novice researchers. Little is known about the challenges that the novice researcher faces while conducting sensitive, emotionally laden research. This is exacerbated where participants of such studies have little/no idea about expressing the value of a particular research study (i.e., where the first question to arise from the participants is "what would be my benefit if I participate in your research?"). Based on the student researcher's self-reflections, this article focuses on the inherent challenges that a researcher faced while conducting in-depth interviews among a group of emotionally vulnerable people-survivors of the disastrous Rana Plaza collapse in Bangladesh. It suggests how the challenges can be reduced or mitigated, and the researcher's self-care can be ensured. It also raises important methodological questions, including whether in-depth narrative interviews are appropriate in relation to those living with significantly different cultural norms.

Undertaking rapid evaluations during the COVID-19 pandemic: Lessons from evaluating COVID-19 remote home monitoring services in England

Introduction

Rapid evaluations can offer evidence on innovations in health and social care that can be used to inform fast-moving policy and practise, and support their scale-up according to previous research. However, there are few comprehensive accounts of how to plan and conduct large-scale rapid evaluations, ensure scientific rigour, and achieve stakeholder engagement within compressed timeframes.

Methods

Using a case study of a national mixed-methods rapid evaluation of COVID-19 remote home monitoring services in England, conducted during the COVID-19 pandemic, this manuscript examines the process of conducting a large-scale rapid evaluation from design to dissemination and impact, and reflects on the key lessons for conducting future large-scale rapid evaluations. In this manuscript, we describe each stage of the rapid evaluation: convening the team (study team and external collaborators), design and planning (scoping, designing protocols, study set up), data collection and analysis, and dissemination.

Results

We reflect on why certain decisions were made and highlight facilitators and challenges. The manuscript concludes with 12 key lessons for conducting large-scale mixed-methods rapid evaluations of healthcare services. We propose that rapid study teams need to: (1) find ways of quickly building trust with external stakeholders, including evidence-users; (2) consider the needs of the rapid evaluation and resources needed; (3) use scoping to ensure the study is highly focused; (4) carefully consider what cannot be completed within a designated timeframe; (5) use structured processes to ensure consistency and rigour; (6) be flexible and responsive to changing needs and circumstances; (7) consider the risks associated with new data collection approaches of quantitative data (and their usability); (8) consider whether it is possible to use aggregated quantitative data, and what that would mean when presenting results, (9) consider using structured processes & layered analysis approaches to rapidly synthesise qualitative findings, (10) consider the balance between speed and the size and skills of the team, (11) ensure all team members know roles and responsibilities and can communicate quickly and clearly; and (12) consider how best to share findings, in discussion with evidence-users, for rapid understanding and use.

Conclusion

These 12 lessons can be used to inform the development and conduct of future rapid evaluations in a range of contexts and settings.

From Zero to a National Data Set in 2 Weeks: Reflections on a COVID-19 Collaborative Survey Project

In March 2020, like much of the rest of the world, we went into lockdown. A week into our new reality, we decided to do a survey study about how people were experiencing the COVID-19 pandemic. In this piece, we describe what motivated us to do the study, how we went about it, and what others can learn from our experiences.

Chasing scorpions across North Africa: Ethical reflections on life story research with Sub-Saharan migrants

In this Research Note, two researchers present their reflections on the ethical challenges they encountered while collecting life stories of sub-Saharan migrants in Morocco and the Disputed Territory of Western Sahara. The reflections are based on field notes and excerpts from unedited transcripts of daily debriefing sessions that the researchers undertook together. The sessions were audio-recorded and transcribed into written notes. The materials reveal their thoughts and feelings as they grappled with the ethics of keeping their research participants ("Narrators") safe, working with community organizations on the ground, attempting to conduct interviews as humanely as possible, while also managing and concealing their own emotions.

Reflections on the Concomitants of the Restrictive Visitation Policy During the COVID-19 Pandemic: An Ubuntu Perspective

Caregiving is a prominent concept in the Ubuntu philosophy, and caring and visitation of the sick is regarded as an example of Ubuntu. The restrictive visitation policy adopted in the hospitals during the coronavirus disease 2019 (COVID-19) pandemic affected the exhibition of this concept among patients, nurses, and families. The narrative inquiry was used to explore the reflections of the participants on the impact caused by the non-visitation policy experienced during the first and second waves of the COVID-19 pandemic in South Africa. The narrative inquiry approach allowed the participants to tell their story as it is unique to them. The study used purposive sampling technique to select five participants for the webinar. Three themes emerged from the narrated stories which are 1) moral anguish of the caregivers; 2) mental health instability, and 3) erosion of trust in health care practitioners (HCPs). The non-visitation hospital policy was intended to reduce the danger of spreading COVID-19 within and outside the hospital; however, the care provided was devoid of the values of Ubuntu such as mutual respect, relational, responsibility, reciprocity, and interconnectedness. In retrospect, a case-by-case application of the policy would reduce the non-desirable effect of the policy on the patients, nurses, and patients' family members.

Developing a competency-based undergraduate logbook for pediatrics: Process and lessons

With the first MBBS batch admitted under the new National Medical Commission (NMC) undergraduate curriculum entering pediatric clinical posting soon, creation of a Pediatric logbook in consonance with this competency-based curriculum was felt to be a need of the hour. No such document is yet available in the public domain. The logbook template, created after enormous brainstorming amongst authors, includes 176 Shows (S), Shows How (SH) and Perform (P) level competencies. These were further segregated into certifiable (23), affective domain (25) and clinic/field visits (9) leaving 51 as documentable competencies. The institutions may use this template to build their own institute-specific logbook based on the infrastructure, faculty strength, clinical patient load, student intake and preferred assessment method(s). It would also be worthwhile to integrate this with the internship logbook (and later the postgraduate one for students opting for post-graduation in pediatrics) to provide a longitudinal record of each student's trajectory of learning.

Curly Questions

This letter reflects on my collaborations with Nick Martin over the past 18 years. Working together we have applied twin-family and statistical genetics methods to examine the genetic architecture and identify genetic variants influencing a range of physical, psychological and social traits. The common thread across much of this work has been the empirical questions: Why are we the way we are and how can this knowledge help us when things go wrong?

Some Reflections on the 50th Anniversary of Hospice Care in America

This article celebrates the 50th anniversary of hospice care in America. It also offers a brief recounting of one person's reflections on some aspects of the history, achievements, and current status of American hospice care.

Generation of Backward-Looking Complex Reflections for a Motivational Interviewing-Based Smoking Cessation Chatbot Using GPT-4: Algorithm Development and Validation

Background

Motivational interviewing (MI) is a therapeutic technique that has been successful in helping smokers reduce smoking but has limited accessibility due to the high cost and low availability of clinicians. To address this, the MIBot project has sought to develop a chatbot that emulates an MI session with a client with the specific goal of moving an ambivalent smoker toward the direction of quitting. One key element of an MI conversation is reflective listening, where a therapist expresses their understanding of what the client has said by uttering a reflection that encourages the client to continue their thought process. Complex reflections link the client's responses to relevant ideas and facts to enhance this contemplation. Backward-looking complex reflections (BLCRs) link the client's most recent response to a relevant selection of the client's previous statements. Our current chatbot can generate complex reflections-but not BLCRs-using large language models (LLMs) such as GPT-2, which allows the generation of unique, human-like messages customized to client responses. Recent advancements in these models, such as the introduction of GPT-4, provide a novel way to generate complex text by feeding the models instructions and conversational history directly, making this a promising approach to generate BLCRs.

Objective

This study aims to develop a method to generate BLCRs for an MI-based smoking cessation chatbot and to measure the method's effectiveness.

Methods

LLMs such as GPT-4 can be stimulated to produce specific types of responses to their inputs by "asking" them with an English-based description of the desired output. These descriptions are called prompts, and the goal of writing a description that causes an LLM to generate the required output is termed prompt engineering. We evolved an instruction to prompt GPT-4 to generate a BLCR, given the portions of the transcript of the conversation up to the point where the reflection was needed. The approach was tested on 50 previously collected MIBot transcripts of conversations with smokers and was used to generate a total of 150 reflections. The quality of the reflections was rated on a 4-point scale by 3 independent raters to determine whether they met specific criteria for acceptability.

Results

Of the 150 generated reflections, 132 (88%) met the level of acceptability. The remaining 18 (12%) had one or more flaws that made them inappropriate as BLCRs. The 3 raters had pairwise agreement on 80% to 88% of these scores.

Conclusions

The method presented to generate BLCRs is good enough to be used as one source of reflections in an MI-style conversation but would need an automatic checker to eliminate the unacceptable ones. This work illustrates the power of the new LLMs to generate therapeutic client-specific responses under the command of a language-based specification.

Lockdown Learnings: No Longer the Mirrored Room

During the COVID-19 lockdown in Aotearoa/New Zealand, a discussion panel was convened comprising of family therapy students and experienced family therapists to investigate the effects of the use of online digital mediums for family therapy. This article discusses the learnings from that panel. It seems that the use of a screen can change the power dynamic between therapist and client family, perhaps levelling the field slightly and resulting in implications for the therapeutic relationship. Suggestions for practice are given and the situation is likened to that of the 'mirrored room' proposed by Hare-Mustin (1994).