Caring, competence and professional identities in medical education

Mentoring as a complex adaptive system - a systematic scoping review of prevailing mentoring theories in medical education

BACKGROUND

Effective mentorship is an important component of medical education with benefits to all stakeholders. In recent years, conceptualization of mentorship has gone beyond the traditional dyadic experienced mentor-novice mentee relationship to include group and peer mentoring. Existing theories of mentorship do not recognize mentoring's personalized, evolving, goal-driven, and context-specific nature. Evidencing the limitations of traditional cause-and-effect concepts, the purpose of this review was to systematically search the literature to determine if mentoring can be viewed as a complex adaptive system (CAS).

METHODS

A systematic scoping review using Krishna's Systematic Evidence-Based Approach was employed to study medical student and resident accounts of mentoring and CAS in general internal medicine and related subspecialties in articles published between 1 January 2000 and 31 December 2023 in PubMed, Embase, PsycINFO, ERIC, Google Scholar, and Scopus databases. The included articles underwent thematic and content analysis, with the themes identified and combined to create domains, which framed the discussion.

RESULTS

Of 5,704 abstracts reviewed, 134 full-text articles were evaluated, and 216 articles were included. The domains described how mentoring relationships and mentoring approaches embody characteristics of CAS and that mentorship often behaves as a community of practice (CoP). Mentoring's CAS-like features are displayed through CoPs, with distinct boundaries, a spiral mentoring trajectory, and longitudinal mentoring support and assessment processes.

CONCLUSION

Recognizing mentorship as a CAS demands the rethinking of the design, support, assessment, and oversight of mentorship and the role of mentors. Further study is required to better assess the mentoring process and to provide optimal training and support to mentors.

Professional identity formation of medical students in relation to the care of older persons: a review of the literature

With the growing population of older persons, medical students have to be well prepared for older persons' health care during medical school. Becoming a doctor is an interplay of building competencies and developing a professional identity. Professional identity formation of medical students is a relatively new educational concept in geriatric medical education. This review aims to explore the concept of professional identity formation of undergraduate medical students in relation to the care of older persons. Twenty-three peer-reviewed studies were included and summarized narratively. Patient-centeredness, caring and compassion, collaboration and holistic care are characteristics of the doctor's professional identity in relation to the care of older persons. Participating in the context of older persons' health care contributes to the becoming of a doctor in general. In this context, the building of relationships with older persons, participating in their lives and role models are important influencers of professional identity formation. Furthermore, the perceptions and expectations medical students have of future doctoring influence their feelings about the care of older persons. To prepare medical students for older persons' health care, professional identity formation seems to be a relevant educational concept.

What makes a 'good doctor'? A critical discourse analysis of perspectives from medical students with lived experience as patients

What constitutes a 'good doctor' varies widely across groups and contexts. While patients prioritise communication and empathy, physicians emphasise medical expertise, and medical students describe a combination of the two as professional ideals. We explored the conceptions of the 'good doctor' held by medical learners with chronic illnesses or disabilities who self-identify as patients to understand how their learning as both patients and future physicians aligns with existing medical school curricula. We conducted 10 semistructured interviews with medical students with self-reported chronic illness or disability and who self-identified as patients. We used critical discourse analysis to code for dimensions of the 'good doctor'. In turn, using concepts of Bakhtinian intersubjectivity and the hidden curriculum we explored how these discourses related to student experiences with formal and informal curricular content.According to participants, dimensions of the 'good doctor' included empathy, communication, attention to illness impact and boundary-setting to separate self from patients. Students reported that formal teaching on empathy and illness impact were present in the formal curriculum, however ultimately devalued through day-to-day interactions with faculty and peers. Importantly, teaching on boundary-setting was absent from the formal curriculum, however participants independently developed reflective practices to cultivate these skills. Moreover, we identified two operating discourses of the 'good doctor': an institutionalised discourse of the 'able doctor' and a counterdiscourse of the 'doctor with lived experience' which created a space for reframing experiences with illness and disability as a source of expertise rather than a source of stigma. Perspectives on the 'good doctor' carry important implications for how we define professional roles, and hold profound consequences for medical school admissions, curricular teaching and licensure. Medical students with lived experiences of illness and disability offer critical insights about curricular messages of the 'good doctor' based on their experiences as patients, providing important considerations for curriculum and faculty development.

Becoming a physician for older patients: exploring the professional identity formation of medical students during a nursing home clerkship. A qualitative study

BACKGROUND

To prepare medical students for the growing population of older patients, an appropriate professional identity formation is desirable. The community of practice of medical school is primarily hospital-based and disease-oriented which will lead to the development of a physician who is mainly focused on cure. This focus alone however is not always appropriate for older persons' health care. The aim of this study is to explore the influence of participating in a nursing home community of practice on the professional identity formation of medical students.

METHODS

A qualitative study based on a constructivist research paradigm was conducted, using individual semi-structured, in-depth interviews and a visual narrative method (drawing) as a prompt. Thematic analysis was applied to structure and interpret the data. The study population consisted of fifth-year medical students participating in a six-week nursing home clerkship. Thirteen participants were purposefully sampled. The clerkship took place in nursing homes in the South-West of the Netherlands.

RESULTS

The medical students described the nursing home as the living environment of the patients. Actively participating in the patients' care and experiencing the daily life of the patients was meaningful for the physician the students want to become in five ways: (1) a physician with a complete picture; (2) a physician who is close; (3) a physician who is in dialogue; (4) a physician who is able to let go and (5) a physican who collaborates.

CONCLUSIONS

Caring for older patients in the nursing home influences the professional identity formation of medical students. Patient-centeredness, personal, holistic and tailored care, approachability and collaboration are important characteristics in becoming a physician for older persons' health care. The context of this care provides relevant learning experiences for this development and the becoming of a physician in general.

Integrating person-centred care and social justice: a model for practice with larger-bodied patients

Person-centred care (PCC) has been touted as a promising paradigm for improving patients' experiences and outcomes, and the overall therapeutic environment for a range of health conditions, including obesity. While this approach represents an important shift away from a paternalistic and disease-focused paradigm, we argue that PCC must be explicitly informed by a social justice lens to achieve optimal conditions for health and well-being. We suggest that existing studies on PCC for obesity only go so far in achieving social justice goals as they operate within a biomedical model that by default pathologises excess weight and predetermines patients' goals as weight loss and/or management, regardless of patients' embodied experiences and desires. There remains a dearth of empirical research on what social justice-informed PCC looks like in practice with larger patients. This interview study fills a research gap by exploring the perspectives of 1) health practitioners (n=22) who take a critical, social justice-informed approach to weight and 2) larger patients (n=20) served by such practitioners. The research question that informed this paper was: What are the characteristics of social justice-informed PCC that play out in clinical interactions between healthcare practitioners and larger-bodied patients? We identified five themes, namely: 1) Integrating evidence-based practice with compassionate, narrative-based care; 2) Adopting a curious attitude about the patient's world; 3) Centring patients' own wisdom and expertise about their conditions; 4) Working within the constraints of the system to advocate for patients to receive equitable care; 5) Collaborating across professions and with community services to address the multifaceted nature of patient health. The findings illustrate that despite participants' diverse perspectives around weight and health, they shared a commitment to PCC by upholding patient self-determination and addressing weight stigma alongside other systemic factors that affect patient health outcomes.

Interrogation in clinical supervision sessions: Exploring the construction of clinical psychology trainees’ professional identities

BACKGROUND

Professional socialisation is a complex process through which learners become healthcare professionals. This process occurs in relational spaces: learners are exposed to norms and expectations of them in interactions during formal and informal learning activities. Research exploring socialisation into the healthcare professions is extensive yet inadequately captures details of the actual processes of socialisation and forming of professional identity. Our study offers a moment-by-moment examination of clinical psychology trainee supervision to provide a deeper exploration of novice healthcare professionals' identity development within formal educational interactions.

AIMS

We sought to explore how, and in what ways, supervision interactions impact clinical psychology trainees' professional identity development.

METHOD

Our data comprises 12 audio recordings of supervisor-trainee interactions in a clinical psychology training clinic. Initial data engagement identified 20 instances of interrogation instigated by supervisors (i.e., repetitive questioning, enquiry) as being key events in which identities are contested and re-negotiated. These sections were transcribed verbatim. Drawing on positioning, framing and impression management theories, we explored identity construction in interrogations using discourse analysis.

RESULTS

Supervisors approached interrogations of trainees from either a quality control or a reflective frame focusing on the client or trainee respectively. These frames influenced the positions being made available to trainees. Reflective frame interrogations often defaulted back to quality control. Trainees employed impression management tactics to manage perceived face-threat.

DISCUSSION

Findings highlight challenges with maintaining a reflective space in supervision during interrogations. Supervisors had authority to initiate interrogations that could be taken up, negotiated or resisted by trainees, ultimately maintaining certain professional knowledge and truths. We illuminate the ways in which socialisation processes at the interactional level during formal learning activities ultimately make available (and restrict) certain ways for trainees to think, feel and be.

Technologies, Physician's Caring Competency, and Patient Centered Care:A Systematic Review

This study aimed to conduct a systematic review to clarify patient understanding, understanding of caring concepts, understanding of technology, competency to express compassion, appropriate involvement in caring, and ethical and moral attitudes and responses toward patients. This systematic review was conducted through an electronic search across PubMed, Google Scholar, MEDLINE, and Science Direct. Authors independently appraised the methodological quality of the studies using the Mixed Method Appraisal Tool. A narrative synthesis approach was used to present these findings. Nine studies met the inclusion criteria and quality appraisal guidelines. Through thematic analysis, four major themes were identified:Technology and caring competency, Technology and patient-centered care, Empathetic skills, and Caring competency. This review has shown that patients choose physicians considering their emotions and communicate well with them, empowering them to take responsibility of their own or their loved ones' healthcare. In the age of technological advancement and availability of vast sources of information, it is expected of physicians to adapt to these character priorities while maintaining their sense of humanness, not only focusing on healing modalities, but also to guide, educate, and appropriately empower their patients toward achieving their healthcare goals. J. Med. Invest. 70 : 307-316, August, 2023.

Does your group matter? How group function impacts educational outcomes in problem-based learning: a scoping review

BACKGROUND

Problem-based learning (PBL) is a common instructional method in undergraduate health professions training. Group interactions with and within PBL curricula may influence learning outcomes, yet few studies have synthesized the existing evidence. This scoping review summarized the literature examining the influence of group function on individual student PBL outcomes. Following Kirkpatrick's framework, experiential, academic, and behavioral outcomes were considered. The impacts of three aspects of group function were explored: (1) Group Composition (identities and diversity), (2) Group Processes (conduct and climate, motivation and confidence, and facilitation), and (3) PBL Processes (tutorial activities).

METHODS

A literature search was conducted using Medline, CINAHL, and APA PsychInfo from 1980-2021, with the help of a librarian. English-language empirical studies and reviews that related group function to learning outcome, as defined, in undergraduate health professions PBL curricula were included. Relevant references from included articles were also added if eligibility criteria were met. The methods, results, discussions, and limitations of the sample were summarized narratively.

RESULTS

The final sample (n = 48) varied greatly in context, design, and results. Most studies examined junior medical students (n = 32), used questionnaires for data collection (n = 29), and reported immediate cross-sectional outcomes (n = 34). Group Processes was the most frequently examined aspect of group function (n = 29), followed by Group Composition (n = 26) and PBL Processes (n = 12). The relationships between group function and outcomes were not consistent across studies. PBL experiences were generally highly rated, but favorable student experiences were not reliable indicators of better academic or behavioral outcomes. Conversely, problematic group behaviors were not predictors of poorer grades. Common confounders of outcome measurements included exam pressure and self-study.

CONCLUSIONS

The main findings of the review suggested that (1) group function is more predictive of experiential than academic or behavioral PBL outcomes, and (2) different Kirkpatrick levels of outcomes are not highly correlated to each other. More research is needed to understand the complexity of group function in PBL tutorials under variable study contexts and better inform curricular training and design. Standardized tools for measuring PBL group function may be required for more conclusive findings.

Weak inclusion of the medical humanities in medical education: a qualitative study among Danish medical students

BACKGROUND

The modern medical education is predominantly grounded in the biomedical sciences. In recent years, medical humanities have been included into the medical curricula in many countries around the world one of the objectives being to promote patient-centred, empathic care by future physicians. Studies have been made of the impact of inclusion of medical humanities components within the medical curriculum. Although some results suggest increased empathy, others remain inconclusive. To gain insight into the depth, context, and impact of inclusion of the medical humanities for future physicians, this study aimed to explore Danish medical students' understanding of and reflections on how the medical humanities relate to the medical education, including the clinic.

METHODS

We conducted a qualitative research study, involving semi-structured interviews with twenty-three Danish medical students across years of curriculum and medical schools. Interviews were recorded, transcribed verbatim and analyzed using Braun and Clarke's thematic analysis.

RESULTS

The findings demonstrate the subordinate role of the medical humanities in the medical educational system. Students prioritize biomedical knowledge building in the preclinical curriculum, partly as a reaction to an unbalanced institutional inclusion of the medical humanities. Observing how structural empathy incentives are lacking in the clinical curriculum, the values inherent in the medical humanities are undermined.

CONCLUSION

Danish medical students become part of an educational environment with lacking institutional conditions and structures to promote the strong inclusion of the medical humanities. A focus is therefore needed on the values, norms and structures of the medical educational systems that undermine a strong inclusion of the medical humanities into medical education.

A Scoping Review on the Concept of Physician Caring

BACKGROUND

Physicians' interest in the health and well-being of their patients is a tenet of medical practice. Physicians' ability to act upon this interest by caring for and about their patients is central to high-quality clinical medicine and may affect burnout. To date, a strong theoretical and empirical understanding of physician caring does not exist. To establish a practical, evidence-based approach to improve health care delivery and potentially address physician burnout, we sought to identify and synthesize existing conceptual models, frameworks, and definitions of physician caring.

METHODS

We performed a scoping review on physician caring. In November 2019 and September 2020, we searched PubMed MEDLINE, Embase, PsycINFO, CINAHL, and CENTRAL Register of Controlled Trials to identify conceptual models, frameworks, and definitions of physician caring. Eligible articles involved discussion or study of care or caring among medical practitioners. We created a content summary and performed thematic analysis of extracted data.

RESULTS

Of 11,776 articles, we reviewed the full text of 297 articles; 61 articles met inclusion criteria. Commonly identified concepts referenced Peabody's "secret of care" and the ethics of care. In bioethics, caring is described as a virtue. Contradictions exist among concepts of caring, such as whether caring is an attitude, emotion, or behavior, and the role of relationship development. Thematic analysis of all concepts and definitions identified six aspects of physician caring: (1) relational aspects, (2) technical aspects, (3) physician attitudes and characteristics, (4) agency, (5) reciprocity, and (6) physician self-care.

DISCUSSION

Caring is instrumental to clinical medicine. However, scientific understanding of what constitutes caring from physicians is limited by contradictions across concepts. A unifying concept of physician caring does not yet exist. This review proposes six aspects of physician caring which can be used to develop evidence-based approaches to improve health care delivery and potentially mitigate physician burnout.

General practice residents’ perspectives on their professional identity formation: a qualitative study

Objectives

To move beyond professionalism as a measurable competency, medical educators have highlighted the importance of forming a professional identity, in which learners come to ‘think, act, and feel like physicians’. This socialisation process is known as professional identity formation (PIF). Few empirical studies on PIF in residency have been undertaken. None of these studies focused on PIF during the full length of GP training as well as the interplay of concurrent socialising factors. Understanding the socialisation process involved in the development of a resident’s professional identity and the roles of influencing factors and their change over time could add to a more purposeful approach to PIF. Therefore, we aimed to investigate the process of PIF during the full length of General Practice (GP) training and which factors residents perceive as influential.

Design

A qualitative descriptive study employing focus group interviews.

Setting

Four GP training institutes across the Netherlands.

Participants

Ninety-two GP residents in their final training year participated in 12 focus group interviews.

Results

Study findings indicated that identity formation occurs primarily in the workplace, as residents move from doing to becoming and negotiate perceived norms. A tapestry of interrelated influencing factors—most prominently clinical experiences, clinical supervisors and self-assessments—changed over time and were felt to exert their influence predominantly in the workplace.

Conclusions

This study provides deeper empirical insights into PIF during GP residency. Doing the work of a GP exerted a pivotal influence on residents’ shift from doing as a GP to thinking, acting and feeling like a GP, that is, becoming a GP. Clinical supervisors are of utmost importance as role models and coaches in creating an environment that supports residents’ PIF. Implications for practice include faculty development initiatives to help supervisors be aware of how they can perform their various roles across different PIF stages.

The Professional Identity and Career Attitude of Chinese Medical Students During the COVID-19 Pandemic: A Cross-Sectional Survey in China

BACKGROUND

Although professional identity is a strong predictor of career choice, only a few studies have reported on medical students' career attitude during a public health emergency. This study investigates the changes in medical students' professional identity and career attitude during the COVID-19 pandemic, evaluates their mental health and social support system under stress, and explores the relationship between their career attitude and other factors.

METHODS

An online survey of 6,226 Chinese medical students was conducted to collect information on demographics, professional identity, and career attitude. The collected data were assessed using the Patient Health Questionnaire, the Generalized Anxiety Disorder Scale, and the Social Support Rating Scale.

RESULTS

The results revealed that most (80.8%) of the participants did not change their career attitude and the professional identity of most participants strengthened, and they preferred to participate on the frontline during the COVID-19 pandemic. The prevalence of depression and anxiety among medical students was 22.86% and 35.43%. Low social support, depressive symptoms, male gender, and higher grades were factors that negatively affected career attitude.

CONCLUSIONS

After the outbreak of the pandemic, it was necessary to conduct diversified professional identity research to support medical students, especially those with low social support and depressive symptoms.

Paradox of Patient-Centered Care and the Implications for Patient Involvement in Continuing Professional Development

INTRODUCTION

Patient-centered care (PCC) is widely considered as essential in chronic disease management. As the underlying rationale for engaging patients in continuing professional development (CPD) is commonly described as fostering care that is more patient-centered, we hoped to understand the discursive conditions for how educators and health professionals can (or cannot) learn with, from, and about patients.

METHODS

Using diabetes as a case, we conducted a Foucauldian discourse analysis of an archive of relevant policy documents, professional and educational texts, to explore different conceptualizations of practice and the implications for PCC. We also conducted in-depth interviews with a purposive sample of physicians to understand their experiences in providing and teaching PCC. We sought to understand: How has PCC been discursively constructed? Whose interests does advocating PCC serve? What are the implications for patient involvement in CPD?

RESULTS

We describe three discursive constructions of PCC, each extending the reach of biomedical power. PCC as a disease intervention emphasizes knowing and relating to patients to normalize laboratory test results. PCC as a form of confession promotes patients to come to their own realizations to become responsible for their own health, but through the lens and evaluation of physicians. PCC as a disciplinary technique makes visible the possibility of using a checklist to judge physician competency in providing PCC.

DISCUSSION

PCC may be constructed in ways that paradoxically reinforce rather than challenge conventional, provider-centric paradigms. Our results challenge educators to acknowledge the existence and effects of discourses when involving patients in the planning and delivery of CPD.

Learner conceptions of health advocacy: 'Going above & beyond' or 'kind of an expectation'

CONTEXT

Health advocacy is a core component of physician competency frameworks. However, advocacy has lacked a clear definition and is understood and enacted variably across contexts. Due to their mobility across contexts, learners are uniquely positioned to provide insight into the tensions that have made this role so difficult to define, but that may be central to this role. The purpose of this study was to map the tensions and contours in conceptions of health advocacy among learners across a variety of learning contexts.

METHODS

We used constructivist grounded theory and interviewed nine medical students and twenty residents in family, paediatric and internal medicine from across our university's distributed programmes. Data were analysed concurrently using open, focussed and theoretical coding to establish themes and relationships between themes.

RESULTS

Learners understood health advocacy in two overlapping but distinct ways: as a set of behaviours and as a sense of 'going above and beyond', through additional effort, time or risk. These two conceptions overlapped and were often in tension. 'Going above and beyond' sometimes aligned with identifiable advocacy behaviours; at other times, 'going above and beyond' did not align with definitions of health advocacy in competency frameworks and aligned more closely with 'patient-centred care'.

CONCLUSIONS

Our findings suggest that learners perceive that there are important elements of health advocacy that cannot be captured in universal behaviours that apply across contexts. 'Going above and beyond' describes a sense of grappling with sociocultural barriers to patient-centred care and striving towards better systems and better care for individuals. This more abstract and contextually bound notion of health advocacy may not lend itself easily to definition in competency frameworks and thus adds challenges to both teaching and assessment.

Competent to provide compassionate care? A critical discourse analysis of accreditation standards

BACKGROUND

Medical school accreditation is recognised internationally as an important quality control process for programmes that lead to the Medical Doctor (MD) degree. Accreditation standards govern the accreditation process which in turn drives educational objectives. Given the power of these standards to shape what becomes valued in the curricula, it is therefore imperative to ensure that core values and ideals of the profession are meaningfully incorporated. As the provision of compassionate care has long been a central medical value, this value should be clearly articulated in MD programme accreditation standards.

METHODS

We conducted a Critical Discourse Analysis of compassionate care within Undergraduate Medical Education (UME) Accreditation Standards governing North American medical schools since 1957. We explored how and to what extent the written language of the accreditation standards incorporated compassionate care.

RESULTS

References to compassionate care in the UME Accreditation Standards were few and far between. Historically, a statement of 'The Objectives of Undergraduate Medical Education' published by the Association of American Medical Colleges (AAMC) was referenced for the first and only time in the 1957 standards, describing the development of attributes such as the provision of compassionate care as a basic objective of UME. Thereafter, there was infrequent mention of this value. Terms that could potentially incorporate aspects of compassionate care were identified, yet these were explicated in ways that limited connection to compassion. Instead, the term 'care' has increasingly been used instrumentally (ie acute care, chronic care).

CONCLUSION

The relative absence of language pertaining to compassionate care in accreditation standards is troubling as compassion is integral to good medical care. This absence is particularly important to attend to in the current era of competency-based training where we must be explicit about all important curricular objectives lest essential values and practices be unintentionally lost.

Adverse events as transitional markers - Using liminality to understand experiences of second victims

Healthcare professionals are socialized into a tacit, professional identity of competences and skills - to save lives, repair trauma and facilitate good and trustful relational care. When severe adverse events happen, healthcare professionals may struggle to accept their own fallibility, and the event may pose a threat to the selfdeclared 'superior' or 'infallible' professional identity. The consequences of a sudden identity shift between the 'potentially infallible HCP' and 'potentially fallible HC P' caused by an adverse event is the analytical object of this study. The aim of the paper is to derive new understandings of how HCPs in maternity services experience adverse events by using Arnold van Gennep's and Victor Turner's 'rites of passage' theorizations and the concept of liminality to explain the process of transition between the two professional identities. Through five focus groups conducted in June 2018 with midwives and obstetricians-gynecologists, we have examined i) how second victim experiences can be understood using theories of transition and liminality, and ii) how the organizational procedures in a Danish university hospital may serve as a ritual for the involved HCPs in the aftermath of adverse events. The findings suggest that the inconsistency in the level of support contributes to the chaos that may be experienced by the healthcare professional. The organizational structure does not provide rites of transition or any other ritual processes, except for debriefings that, in many cases, are experienced as deficient. Since liminal states suggest danger and threat, because the previous professional identity is replaced by ambiguity and separation, the lack of clear rituals and support may put further strain on the HCP adding to the associated psychological and social distress. Considering the liminality and the need for structured transition rites within the work environment may prove useful when constructing adequate second victim support programs.

Harmony or dissonance? The affordances of palliative care learning for emerging professional identity

INTRODUCTION

Patient demographics demand physicians who are competent in and embrace palliative care as part of their professional identity. Published literature describes ways that learners acquire knowledge, skills and attitudes for palliative care. These studies are, however, limited by their focus on the individual where learning is about acquisition. Viewing learning as a process of becoming through the interplay of individual, social relationships and cultures, offers a novel perspective from which to explore the affordances for professional identity development.

METHODS

Qualitative narrative methods were used to explore 45 narratives of memorable learning (NMLs) for palliative care recounted by 14 graduating family medicine residents in one family medicine residency program. Thematic and narrative analyses identified the affordances that support and constrain the dynamic emergence of professional identity.

RESULTS

Participants recounted affordances that supported and/or constrained their learning acting on personal (e.g. past experiences of death), interpersonal (e.g. professional support) and systemic (e.g. patient continuity) levels. Opportunities for developing professional identity were dynamic: factors acted in harmony, were misaligned, or colliding to support or constrain an emerging professional identity for palliative care practice.

CONCLUSION

Findings highlight how individual factors interplay with interpersonal and structural conditions in the workplace in dynamic and emergent ways that may support or constrain the emergence of professional identity. Viewing learning as a process of becoming allows teachers, curriculum developers and administrators to appreciate the complexity and importance of the interplay between the individual and the workplace affordances to create environments that nurture professional identity for palliative care practice.

The Hidden Curriculum in Ethics and its Relationship to Professional Identity Formation: A Qualitative Study of Two Canadian Psychiatry Residency Programs

The residency years comprise the last period of a physician’s formal training. It is at this stage that trainees consolidate the clinical skills required for independent practice and achieve a level of ethical development essential to their work as physicians, a process known as professional identity formation (PIF). Ethics education is thought to contribute to ethical development and to that end the Royal College of Physicians and Surgeons of Canada (RCPSC) requires that formal ethics education be integrated within all postgraduate specialty training programs. However, a formal ethics curriculum can operate in parallel with informal and hidden ethics curricula, the latter being more subtle, pervasive, and influential in shaping learner attitudes and behavior. This paper reports on a study of the formal, informal, and hidden ethics curricula at two postgraduate psychiatry programs in Canada. Based on the analysis of data sources, we relate the divergences between the formal, informal, and hidden ethics curricula to two aspects of professional identity formation (PIF) during psychiatry residency training. The first is the idea of group membership. Adherence to the hidden curriculum in certain circumstances determines whether residents become part of an in-group or demonstrate a sense of belonging to that group. The second aspect of PIF we explore is the ambiguous role of the resident as a student and a practitioner. In ethically challenging situations, adherence to the messages of the hidden curriculum is influenced by and influences whether residents act as students, practitioners, or both. This paper describes the hidden curriculum in action and in interaction with PIF. Our analysis offers a complementary, empirical perspective to the theoretical literature concerning PIF in medical education. This literature tends to position sound ethical decision-making as the end result of PIF. Our analysis points out that the mechanism works in both directions: how residents respond to hidden curriculum in ethics can be a driver of professional identity formation.

Transformative medical education: must community-based traineeship experiences be part of the curriculum? A qualitative study

BACKGROUND

There are shortcomings in medical practitioners' capacity to adapt to the particular needs of people experiencing circumstances of social vulnerability. Clinical traineeships create opportunities for the acquisition of knowledge, competencies, attitudes, and behaviors. However, some authors question the learnings to be made through classical clinical training pathways. This article explores the learnings gained from a traineeship experience within a community-based clinical setting intended for patients experiencing social vulnerability and operating under an alternative paradigm of care. To our knowledge, there is little research intended to identify and understand what medical trainees gain from their experience in such contexts.

METHODS

This exploratory qualitative study is based on twelve interviews with practicing physicians who completed a traineeship at La Maison Bleue (Montreal, Canada) and three interviews conducted with key informants involved in traineeship management. Based on Mezirow's theory of transformational learning, data were analyzed according to L'Écuyer's principles of qualitative content analysis. NVivo software was used.

RESULTS

The main learnings gained through the traineeship are related to (1) greater awareness of beliefs, assumptions and biases through prejudice deconstruction, cultural humility and critical reflection on own limitations, power and privileges; (2) the development of critical perspectives regarding the health care system; (3) a renewed vision of medical practice involving a less stigmatizing approach, advocacy, empowerment, interdisciplinarity and intersectorality; and (4) strengthened professional identity and future practice orientation including confirmation of interest for community-based practice, the identification of criteria for choosing a future practice setting, and commitment to becoming an actor of social change. Certain characteristics of the setting, the patients and the learner's individual profile are shown to be factors that promote these learnings.

CONCLUSIONS

This article highlights how a traineeship experience within a clinical setting intended for a clientele experiencing circumstances of social vulnerability and operating under an alternative paradigm presents an opportunity for transformative learning and health practice transformation toward renewed values of health equity and social justice. Our findings suggest medical traineeships in community-based clinical settings are a promising lead to foster the development of fundamental learnings that are conducive to acceptable and equitable care for people experiencing social vulnerability.

Social Interactions of Clerks: The Role of Engagement, Imagination, and Alignment as Sources for Professional Identity Formation

PURPOSE

Participating in clinical practice shapes students' identities, but it is unclear how students build meaningful relationships while "dipping into" various social contexts. This study explored with whom students interacted, which social relationships they built, and how these relationships contributed to the formation of a professional identity.

METHOD

In this longitudinal study at University Medical Center Groningen, University of Groningen, the Netherlands, 9 undergraduate medical students recorded experiences of thinking about themselves as future professionals (September 2015 to March 2017). The authors conducted template analysis using both open coding and a priori themes derived from Wenger's modes of belonging to communities of practice: engagement, imagination, and alignment.

RESULTS

The authors received 205 recorded experiences. While rotating, students used engagement, imagination, and alignment to give meaning to clinical workplace social interactions. Participants considered relationships with doctors, patients, and peers as preconditions for engaging in meaningful experiences. Although imagination and alignment were less represented, discussing imagination with peers and physicians stimulated a deeper understanding of what it means to become a physician. Explicitly being invited "to the table" and awareness of the benefits of being a clerk were instances of alignment that stimulated the development of identities as future doctors.

CONCLUSIONS

To understand the nature of professional identity formation, Wenger's modes of belonging must be considered. Where engagement is very prevalent, imagination and alignment are less spontaneously mentioned and therefore more difficult to foster. Looking for ways to support imagination and alignment is important for students' sensemaking process of becoming a doctor.

'There shouldn't be anything wrong with not knowing': epistemologies in simulation

CONTEXT

Medical education embraces simulation-based education (SBE). However, key SBE features purported to support learning, such as learner safety and learning through experience and error, may not align with the dominant culture of medicine, in which portraying confidence and certainty about one's knowledge prevails. Misaligned conceptions about knowledge and learning may produce unintended negative effects, including the suboptimal implementation of SBE, which could consequently compromise SBE and its outcomes.

METHODS

To uncover the epistemological beliefs of students experiencing SBE, we conducted a theory-informed analysis of interviews with 24 pre-clerkship medical students following their participation in an SBE training study. Our analysis borrowed from coding methods common in constructivist grounded theory and used Hofer and Pintrich's four dimensions of epistemology as sensitising concepts.

RESULTS

Participants subscribed to a dominant view of knowledge as consisting of concrete facts, derived from external sources. By contrast, they described but did not prioritise a conception of building their own knowledge through different learning experiences. Participants positioned experts (i.e. teaching faculty members) as the ultimate knowledge validators through their presence and feedback. Participants also noted that faculty staff could counter medicine's pressures to perform with certainty and confidence at all times by instead embodying and modelling an authentic appreciation of learning through experiences, errors and discovery.

CONCLUSIONS

Medicine's tendency to idealise the objective pursuit of singular truths may compromise the purported culture of SBE as a space for learning many wide-ranging aspects of medicine, including how and when to innovate and deviate from norms. Explicit attempts to bridge the epistemological beliefs of medicine and SBE may better enable the realisation of safe experiential learning. Faculty members are positioned to play key roles in enabling this bridging.

Navigating Tensions of Efficiency and Caring in Clerkship: A Qualitative Study

Phenomenon: Clerkship is a challenging transition during which medical students must learn to navigate the responsibilities of medical school and clinical medicine. We explored how clerks understand their roles as both medical learners and developing professionals and some of the tensionss that arise therein. Understanding how the clinical learning environment shapes the clerkship role can help educators foster compassionate care. Approach: We conducted 5 focus groups and 1 interview with 3rd-year medical students (n = 14) at University of Toronto between January and June 2016 regarding the perceived role of the clerk, compassionate care, assessment and feedback. Data were analyzed thematically. Findings: In addition to transitioning to a new learning environment, clerkship students assume different roles in response to complex and often competing expectations from preceptors. We identified three main themes: learning to impress preceptors with varying expectations, providing compassionate care-sometimes supported by preceptors, other times being secondary to efficiency-and passing assessments that required a different skill set than simply being a "good clerk." Insights: Clerks perceive their role as providing compassionate care to patients and balance this with fulfilling the (sometimes) competing roles of being a student and developing medical professional. In a system where efficiency is often prioritized, medical students are afforded an opportunity to help satisfy the demand for greater compassion in patient-centered care.

The Divergence and Convergence of Critical Reflection and Critical Reflexivity: Implications for Health Professions Education

As a field, health professions education (HPE) has begun to answer calls to draw on social sciences and humanities (SS&H) knowledge and approaches for curricular content, design, and pedagogy. Two commonly used SS&H concepts in HPE are critical reflection and critical reflexivity. But these are often conflated, misunderstood, and misapplied. Improved clarity of these concepts may positively affect both the education and practice of health professionals. Thus, the authors seek to clarify the origins of each, identify the similarities and differences between them, and delineate the types of teaching and assessment methods that fit with critical reflection and/or critical reflexivity. Common to both concepts is an ultimate goal of social improvement. Key differences include the material emphasis of critical reflection and the discursive emphasis of critical reflexivity. These similarities and differences result in some different and some similar teaching and assessment approaches, which are highlighted through examples. The authors stress that all scientific and social scientific concepts and methods imported into HPE must be subject to continued scrutiny both from within their originating disciplines and in HPE. This continued questioning is core to the ongoing development of the HPE field and also to health professionals' thinking and practice.

'Waiting in the wings'; Lived experience at the threshold of clinical practice

CONTEXT

The transition to clinical practice is challenging. Lack of preparedness and issues with support, responsibility and complex workplace interactions contribute to the difficulties encountered. The first year of clinical practice is associated with negative consequences for new doctors' health and well-being. The contemporaneous lived experience of new graduates on the threshold of clinical practice has not been described. Deeper understanding of this phase may inform interventions to ease the transition from student to doctor.

METHODS

We used interpretative phenomenological analysis (IPA) to explore the individual experience of making the transition from medical student to doctor, focusing on the period prior to commencing clinical practice. Fourteen recent graduates were purposively recruited, and semi-structured interviews were conducted with each, with respect to how they anticipated the transition.

RESULTS

We draw on the metaphor of the actor 'waiting in the wings' to describe participants' lived experience on the threshold of practice. The experience of the actor, about to step into the spotlight, was mirrored in participants' perceptions of an abrupt transformation to come, mixed feelings about what lay ahead, and the various strategies that they had planned to help them to perform their new role convincingly.

DISCUSSION

Participants in this study braced themselves for a trial by ordeal as they contemplated commencing clinical practice. The hidden curriculum shaped their understanding of what was expected of them as new doctors, and inspired dysfunctional strategies to meet expectations. Solutions to make the experience a more positive one lie in the approximation of the roles of senior medical student and newly qualified doctor, in explicitly addressing the hidden curriculum and generating cultural change. An emphasis on experience-based learning through contribution to patient care, guided reflection on the hidden curriculum and shifting cultural expectations through faculty development and strong local leadership can contribute to these objectives.

"Learning the Lingo": A Grounded Theory Study of Telephone Talk in Clinical Education

PURPOSE

Workplace-learning literature has focused on doing, but clinical practice also involves talking. Clinicians talk not only with patients but also about patients with other health professionals, frequently by telephone. The authors examined how the underexplored activity of work-related telephone talk influences physicians' clinical education.

METHOD

Using constructivist grounded theory methodology, the authors conducted 17 semistructured interviews with physicians-in-training from various specialties and training levels from two U.S. academic health centers between 2015 and 2017. They collected and analyzed data iteratively using constant comparison to identify themes and explore their relationships. They used theoretical sampling in later stages until sufficiency was achieved.

RESULTS

Residents and fellows reported speaking via telephone regularly to facilitate patient care and needing to tailor their talk to the goal(s) of the conversation and their conversation partners. Three common conversational situations highlighted the interplay of patient care context and conversation and created productive conversational tensions that influenced learning positively: experiencing and dealing with (1) power differentials, (2) pushback, and (3) uncertainty.

CONCLUSIONS

Telephone talk contributes to postgraduate clinical education. Through telephone talk, physicians-in-training learn how to talk; they also learn through talk that is mediated by productive conversational tensions. These tensions motivate them to modify their behavior to minimize future tensions. When physicians-in-training improve how they talk, they become better advocates for their patients and more effective at promoting patient care. Preparing residents to deal with power differentials, pushback, and uncertainty in telephone talk could support their learning from this ubiquitous workplace activity.

Development of a scale to evaluate medical professional identity formation

BACKGROUND

Medical educators now focus on professional identity formation (PIF), which is a process of psychological development and socialization in the community of practice. This study aimed to develop an instrument to evaluate PIF that can be applied to a large group of medical trainees.

METHODS

A self-administered questionnaire was created with items on priorities, behavior standards, attitudes, and emotional control of well-developed physicians, in addition to items on their background and experience in playing the role of a physician. The participants were divided into four respondent groups: 4th- and 6th-year medical students and 2nd-year residents at Kagoshima University, and experienced medical doctors (instructors).

RESULTS

Using factor analysis of data from 318 respondents and respondent group comparison, a developing scale (DS) with 15 items was created. The DS has a five-factor structure and evaluates self-control as a professional (factor 1), awareness of being a medical doctor (factor 2), reflection as a medical doctor (factor 3), execution of social responsibility (factor 4), and external and internal self-harmonization (factor 5). The mean DS score of the instructors was significantly higher than that of the residents (p < 0.01), the mean score of residents and instructors was significantly higher than that of students (p < 0.01), and the mean score of instructors was significantly higher than that of all other respondents (p < 0.01). Respondent group, but not gender, was a significant variable of the DS. The DS and scores of factors 2 and 4 correlated with 6th-year medical students' experience in playing the role of a physician during clinical training, and scores of factors 3 and 4 correlated with 2nd-year residents' experience in playing the role of a physician. There was no significant difference between the mean DS score of 4th- and 6th-year medical students, which might due to less clinical experience among 6th-year medical students or a limitation of the scale to evaluate pre-clinical medical students.

CONCLUSIONS

The DS could be a useful indicator of medical trainees' personal and professional development and socialization. Experience in playing the role of a physician might facilitate medical trainees' PIF.

Is research on professional identity formation biased? Early insights from a scoping review and metasynthesis

OBJECTIVE

Despite a recent surge in literature identifying professional identity formation (PIF) as a key process in physician development, the empiric study of PIF in medicine remains in its infancy. To gain insight about PIF, the authors examined the medical literature and that of two other helping professions.

METHODS

The authors conducted a scoping review and qualitative metasynthesis of PIF in medicine, nursing and counselling/psychology. For the scoping review, four databases were searched using a combination of keywords to identify empiric studies on PIF in trainees. After a two-step screening process, thematic analysis was used to conduct the metasynthesis on screened articles.

RESULTS

A total of 7451 titles and abstracts were screened; 92 studies were included in the scoping review. Saturation was reached in the qualitative metasynthesis after reviewing 29 articles.

CONCLUSION

The metasynthesis revealed three inter-related PIF themes across the helping professions: the importance of clinical experience, the role of trainees' expectations of what a helping professional is or should be, and the impact of broader professional culture and systems on PIF. Upon reflection, most striking was that only 10 of the 92 articles examined trainee's sociocultural data, such as race, ethnicity, gender, sexual orientation, age and socio-economic status, in a robust way and included them in their analysis and interpretation. This raises the question of whether conceptions of PIF suffer from sociocultural bias, thereby disadvantaging trainees from diverse populations and preserving the status quo of an historically white, male medical culture.

What Experiences in Medical School Trigger Professional Identity Development?

Phenomenon: This qualitative inquiry used conceptual change theory as a theoretical lens to illuminate experiences in medical school that trigger professional identity formation. According to conceptual change theory, changes in personal conceptualizations are initiated when cognitive disequilibrium is introduced. We sought to identify the experiences that trigger cognitive disequilibrium and to subsequently describe students' perceptions of self-in-profession prior to the experience; the nature of the experience; and, when applicable, the outcomes of the experience. Approach: This article summarizes findings from portions of data collected in a larger qualitative study conducted at a new medical school in the United States that utilizes diverse pedagogies and experiences to develop student knowledge, clinical skills, attitudes, and dispositions. Primary data sources included focus groups and individual interviews with students across the 4 years of the curriculum (audio data). Secondary data included students' comments from course and end-of-year evaluations for the 2013-2017 classes (text data). Data treatment tools available in robust qualitative software, NVivo 10, were utilized to expedite coding of both audio and text data. Content analysis was adopted as the analysis method for both audio and text data. Findings: We identified four experiences that triggered cognitive disequilibrium in relationship to students' perceptions of self-in-profession: (a) transition from undergraduate student to medical student, (b) clinical experiences in the preclinical years, (c) exposure to the business of medicine, and (d) exposure to physicians in clinical practice. Insights: We believe these experiences represent vulnerable periods of professional identity formation during medical school. Educators interested in purposefully shaping curriculum to encourage adaptive professional identity development during medical school may find it useful to integrate educational interventions that assist students with navigating the disequilibrium that is introduced during these periods.

Professionalism and its role in the formation of medical professional identity

Background: The honorable medical profession is on the verge of being reduced to a business. Evidence suggests that professionalism is fading and today's doctors are faced with value-threatening problems and gradually begin to forget their main commitment as medical professionals. Many of the problems faced by doctors are rooted in non-professionalism. Mere education in the science and practice of medicine produces an inefficient medical workforce and leads to the formation of a distorted professional identity. In the past decade, educational innovations targeting the formation of desirable professional identities have been presented and are considered a vital part of medical education for the development of professionalism. The present study was conducted to examine the relationship between the formation of professional identity and professionalism. Professionalism education is essential in the formation of a desirable professional identity. Methods: This review article was done in 2015 through searching databases, such as PubMed, Elsevier, Google Scholar, Ovid, SID, and IranMedex, using keywords of professionalism and professional identity, and medical education. Among the 55 found articles, 30 were assessed and selected for review. Results: The formation of professional identity is a process with the following domains: professionalism, and development of a personal (psychosocial) and a cultural identity, which is derived from the unification of professional, personal, and ethical development. The main components required for the formation of a desirable identity are, therefore, rooted in the dimensions of professionalism and professional development. The need for teaching professionalism has a reciprocal relationship with the formation of professional identity. Conclusion: There is a reciprocal relationship between formation of a desirable professional identity and development and strengthening of professionalism. Modern medical education should be designed to develop professional identity, and professionalism acts as an essential part of its curricula throughout the entire course of a doctor's education, with the aim of acquiring a desirable professional identity.

Compassionate Care in the Age of Evidence-Based Practice: A Critical Discourse Analysis in the Context of Chronic Pain Care

PURPOSE

Health professions education and practice have seen renewed calls to restore compassion to care. However, because of the ways evidence-based practice (EBP) has been implemented in health care, wherein research-based knowledge is privileged, the dominance of EBP may silence clinician and patient experience-based knowledge needed for compassionate care. This study explored what happens when the discourses of compassionate care and EBP interact in practice.

METHOD

Chronic pain management in Canada was selected as the context for the study. Data collection involved compiling an archive of 458 chronic pain texts, including gray literature from 2009-2015 (non-peer-reviewed sources, e.g., guidelines), patient blog posts from 2013-2015, and transcripts of study interviews with 9 clinicians and postgraduate trainees from local pain clinics from 2015-2016. The archive was analyzed using an interpretive qualitative approach informed by critical discourse analysis.

RESULTS

Four manifestations of the discourse of compassionate care were identified: curing the pain itself, returning to function, alleviating suffering, and validating the patient experience. These discourses produced particular subject positions, activities, practices, and privileged forms of knowledge. They operated in response, partnership, apology, and resistance, respectively, to the dominant discourse of EBP. These relationships were mediated by other prevalent discourses in the system: patient safety, patient-centered care, professional liability, interprofessional collaboration, and efficiency.

CONCLUSIONS

Medical education efforts to foster compassion in health professionals and systems need to acknowledge the complex web of discourses-which carry with them their own expectations, material effects, and roles-and support people in navigating this web.

'You put up a certain attitude': a 6-year qualitative study of emotional socialisation

CONTEXT

Emotions play a central role in the professional development of doctors; however, research into how students are socialised to deal with emotions throughout medical school is still lacking.

OBJECTIVES

This study aimed to gain a better understanding of the emotional socialisation of medical students (e.g. how they learn to express and respond to emotions evoked in clinical practice in the process of becoming a doctor).

METHODS

In this longitudinal study, 12 medical students participated in annual, individual, semi-structured interviews, capturing the full 6-year medical school period. We carried out a thematic analysis, which was iterative and inductive.

RESULTS

The socialisation of emotion in the process of becoming a doctor happens in a complex interplay between student and context. We identified two modes of emotional socialisation (e.g. explicit and implicit teaching about emotions), the latter including how the people observed by students express their emotions and how they respond to the emotions expressed by students. Although the main message conveyed to students still seemed one about hiding or suppressing emotion, we found that students were able to identify and build upon the emotional expression and responses they observed in positive role models and managed to create their own opportunities to express their emotions. We found large differences between students in how they perceived, presented and developed themselves.

CONCLUSIONS

Students differ in how they respond to and what they need from their environment and thus may benefit from tailored supervision in learning how to experience, express and respond to emotion. Providing students with real and authentic responsibility for patients and allowing them time and opportunity to talk about emotion might help them to create an emotional space.

What lies beneath? Experiencing emotions and caring in oncology

Medical encounters - while often viewed as centred on conveying clinical knowledge - are also sites of emotion and for exerting emotional labour by healthcare professionals. The temptation to view these encounters as largely 'technical' - an exchange of knowledge or information - can marginalise the complex emotions often experienced by healthcare professionals, and negates the critical work done in these encounters. Drawing on in-depth interviews with 22 Australian medical oncologists, this article explores the experience and meaning of (their) emotions in medical encounters, and the manner in which emotional labour is performed by medical oncologists. Emotions, as it emerges, are central to the 'management' of encounters, ensuring professional sustainability and in 'achieving' clinical outcomes. Here, we broaden understandings of emotionality in oncological work, focusing on emotions as central to the production and enactment of professionalism, relationships and identities across professional careers. We illustrate how the performance of emotional labour reflects a dialectic between notions of 'professionalism' and 'feelings' - which in practice are co-existing and intermingling dimensions of oncology relations - manifested in the practice of 'bounded caring'.

Scientism in Medical Education and the Improvement of Medical Care: Opioids, Competencies, and Social Accountability

Scientism in medical education distracts educators from focusing on the content of learning; it focuses attention instead on individual achievement and validity in its measurement. I analyze the specific form that scientism takes in medicine and in medical education. The competencies movement attempts to challenge old "scientistic" views of the role of physicians, but in the end it has invited medical educators to focus on validity in the measurement of individual performance for attitudes and skills that medicine resists conceptualizing as objective. Academic medicine should focus its efforts instead on quality and relevance of care. The social accountability movement proposes to shift the focus of academic medicine to the goal of high quality and relevant care in the context of community service and partnership with the institutions that together with medicine create and cope with health and with health deficits. I make the case for this agenda through a discussion of the linked histories of the opioid prescribing crisis and the professionalism movement.

What Makes "Difficult Patients" Difficult for Medical Students?

PURPOSE

Physicians can find it challenging to provide high-quality care to "difficult patients." While studies support that medical students also find some patients "difficult," little is known about why they do or how being a student affects their perceptions. The authors conducted this study to gain a deeper understanding of students' experiences with "difficult patients" to inform clinical teaching about effective patient communication and patient-centered care.

METHOD

In 2016, the authors conducted interviews with fourth-year medical students, who were asked to describe patient interactions in which they felt negative emotions toward the patient, as well as describe the clinical setting and their feelings. The authors audiorecorded and transcribed the interviews. Then, using a constructivist grounded theory approach, they reviewed the transcripts, coded the data using a codebook they had developed, and grouped the codes into themes.

RESULTS

Twenty-six students (of 44 volunteers and 180 students invited) were interviewed. Students described negative feelings toward patients and patients' behaviors, which were exacerbated by three situations related to their role and expectations as learners: (1) patients' interference with students' ability to "shine"; (2) patients' interference with students' expectations of patient-centered care; and (3) students' lack of the tools or authority to improve patients' health.

CONCLUSIONS

Educators should consider these findings, which can be explained by the professional identity formation and goal orientation theory frameworks, as they teach medical students to provide high-quality care for patients they find "difficult."

Orienting to Medicine: Scripting Professionalism, Hierarchy, and Social Difference at the Start of Medical School

Nascent medical students' first view into medical school orients them toward what is considered important in medicine. Based on ethnography conducted over 18 months at a New England medical school, this article explores themes which emerged during a first-year student orientation and examines how these scripts resurface across a four-year curriculum, revealing dynamics of enculturation into an institution and the broader profession. We analyze orientation activities as discursive and embodied fields which serve "practical" purposes of making new social geographies familiar, but which also frame institutional values surrounding "soft" aspects of medicine: professionalism; dynamics of hierarchy and vulnerability; and social difference. By examining orientation and connecting these insights to later, discerning educational moments, we argue that orientation reveals tensions between the overt and hidden curricula within medical education, including what being a good doctor means. Our findings are based on data from semi-structured interviews, focus groups, and participant-observation in didactic and clinical settings. This article answers calls within medical anthropology and medical education literature to recognize implicit values at play in producing physicians, unearthing ethnographically how these values are learned longitudinally via persisting gaps between formal and hidden curricula. Assumptions hidden in plain sight call for ongoing medical education reform.

"You're Not Trying to Save Somebody From Death": Learning as "Becoming" in Palliative Care

PURPOSE

Learning can be conceptualized as a process of "becoming," considering individuals, workplace participation, and professional identity formation. How postgraduate trainees learn palliative care, encompassing technical competence, compassion, and empathy, is not well understood or explained by common conceptualizations of learning as "acquisition" and "participation." Learning palliative care, a practice that has been described as a cultural shift in medicine challenging the traditional role of curing and healing, provided the context to explore learning as "becoming."

METHOD

The authors undertook a qualitative narrative study, interviewing 14 residents from the University of Ottawa Family Medicine Residency Program eliciting narratives of memorable learning (NMLs) for palliative care. Forty-five NMLs were analyzed thematically. To illuminate the interplay among themes, an in-depth analysis of the NMLs was done that considered themes and linguistic and paralinguistic features of the narratives.

RESULTS

Forty-five NMLs were analyzed. The context of NMLs was predominantly a variety of clinical workplaces during postgraduate training. Themes clustered around the concept of palliative care and how it contrasted with other clinical experiences, the emotional impact on narrators, and how learning happened in the workplace. Participants had expectations about their identities as doctors that were challenged within their NMLs for palliative care.

CONCLUSIONS

NMLs for palliative care were a complex entanglement of individual experience and social and workplace cultures highlighting the limitations of the "acquisition" and "participation" metaphors of learning. By conceptualizing learning as "becoming," what occurs during memorable learning can be made accessible to those supporting learners and their professional identity formation.

Authoring the identity of learner before doctor in the figured world of medical school

INTRODUCTION

Students enter the 'figured world' of medical school with preconceptions of what it means to be a doctor. The meeting of these early preconceptions and their newly developing identities can create emotional tensions. The aim of this study was to advance our understanding of how such tensions were experienced and managed. Using figured worlds as a theoretical framework we explored students' interactions of preconceptions with their newly developing professional identities in their first year at medical school. Advancing our understanding of this phenomena provided new insights into the complex process of identity formation.

METHODS

This was a qualitative study underpinned by a constructivist epistemology. We ran biannual focus groups with 23 first year students in one UK medical school. Data were recorded, transcribed and then template analysis used to undertake an inductive, iterative process of analysis until it was considered the template provided a detailed representation of the data.

RESULTS

Significant preconceptions associated with the identity of a doctor were 'to help' and 'to be a leader'. These early preconceptions were in conflict with realities of the figured world of medical school creating the emotional tensions of 'being unable to help' and 'lacking power', with implications for interactions with patients. By the end of year one students' negotiated tensions and 'self-authored' their identity as a learner as opposed to an imagined 'as if' identity of a doctor.

DISCUSSION

We revealed how preconceptions associated with becoming a doctor can conflict with a newly developing professional identity highlighting the importance of supporting students to embrace the formation of a 'learner' identity, a necessary part of the process of becoming a doctor.

From being a nurse to becoming a 'different' doctor

Using interpretative phenomenological analysis to make meaning of the experiences of three highly qualified registered nurses who had enrolled in an undergraduate medical programme, this study provides insight into their personal journeys of wanting to become 'different' doctors. In so doing, they conceptualised their future selves as adding clinical reasoning and diagnostic skills to the patient-centred caring ethic of their nursing practice, becoming a multi-skilled community member or helping to fix the health care culture. By customising their identities, e.g. by splinting (aligning with their stronger nursing identity), by enriching current nursing practice with newly acquired theory as medical students or by patching a perceived deficiency (i.e. patient-centredness) in medicine, they tailored their identities. Their journeys had, however, not been the natural progression they had anticipated, threatened by perceived and/or real intrinsic (e.g. working as nurses whilst studying medicine) and extrinsic (e.g. interprofessional rivalry) factors. Rather than being accepted as legitimate newcomers to the medical profession, the women sometimes felt like intruders. Some nursing colleagues accused them of desertion. In response, they generally withheld their identities as nurses or medical students, compartmentalising their group membership. This study has highlighted the role of personal (e.g. prior experience; agency; resilience; personality) and contextual factors in 'becoming' a doctor. A recommendation emerging from this study is the need for interprofessional learning in the medical curriculum to cultivate a health care culture of collaboration rather than competition. Future research is required in terms of how allied health professionals transition to medicine.

The invisible work of distributed medical education: exploring the contributions of audiovisual professionals, administrative professionals and faculty teachers

Distributed medical education (DME) is becoming increasingly prevalent. Much of the published literature on DME has focused on the experiences of learners in distributed programs; however, our empirical work leads us to believe that DME changes the context significantly, not only for learners, but also for other important members of the educational community including audiovisual professionals, administrative professionals and faculty teachers. Based on a three-year ethnographic study, we provide a detailed account of how alliances between various workers involved in DME develop to produce and deliver an undergraduate medical curriculum across geographically separate campuses. We explore the question 'What is the work involved in the delivery of a DME program?' and cast a critical gaze on the essential but invisible, and therefore potentially unrecognized and underappreciated, contributions of AV professionals, administrative professionals, and faculty teachers. Our goal is to make visible the complexity of DME, including the essential contributions of these workers. The study was theoretically framed in sociomateriality and conceptually framed in Star and Strauss' notion of articulation work.

The Big D(eal): professional identity through discursive constructions of 'patient'

CONTEXT

Professional identity formation has become a key focus for medical education. Who one becomes as a physician is contingent upon learning to conceptualise who the other is as a patient, yet, at a time when influential ideologies such as patient-centred care have become espoused values, there has been little empirical investigation into assumptions of 'patient' that trainees take up as they progress through their training.

METHODS

Our team employed a critical discourse analysis approach to transcripts originally produced from a micro-ethnography of medical student learning on an acute care in-patient paediatric ward. The dataset included 20 case presentations and 14 sign-over rounds taken from a 3-week observation period. We paid specific attention to how trainees used language to talk about, refer to and categorise patients.

RESULTS

Identified discourses included patient-as-disease-category, patient-as-educational-commodity and patient-as-marginalised-actor. These discourses conceptualise 'patient' as an entity that is principally biomedical, useful for clinical learning and spoken for and about. Medical student participation in these discourses contributes to an identity that allows them to move further into the professional medical world they are joining.

CONCLUSIONS

We contend that as learners participate in these discourses, they are also performatively produced by them. By making these discourses visible, we can consider how to minimise unintended effects such discourses may cause. Our findings, although limited, offer a glimpse of the effects that those assumptions may have as we look to align better the formation of professional medical identity with the ideals of patient-centred care and socially responsible health care systems.

Residents’ use of mobile technologies: three challenges for graduate medical education

Introduction

The practice of medicine involves, among other things, managing ambiguity, interpreting context and making decisions in the face of uncertainty. These uncertainties, amplified for learners, can be negotiated in a variety of ways; however, the promise, efficiency and availability of mobile technologies and clinical decision supports make these tools an appealing way to manage ambiguity.

Mobile technologies are becoming increasingly prevalent in medical education and in the practice of medicine. Because of this, we explored how the use of mobile technologies is influencing residents’ experiences of graduate medical education.

Methods

We conducted an 18-month qualitative investigation to explore this issue. Our research was conceptually and theoretically framed in sociomaterial studies of professional learning. Specifically, our methods included logging of technology use and related reflexive writing by residents (n=10), interviews with residents (n=12) and interviews with faculty (n=6).

Results

We identified three challenges for graduate medical education related to mobile technology use: (1) efficiency versus critical thinking; (2) patient context versus evidence-based medicine and (3) home/work-life balance.

Discussion

In this digital age, decontextualised knowledge is readily available. Our data indicate that rather than access to accurate knowledge, the more pressing challenge for medical educators is managing how, when and why learners choose to access that information.

What Attitudes and Values Are Incorporated Into Self as Part of Professional Identity Construction When Becoming a Surgeon?

PURPOSE

To make explicit the attitudes and values of a community of surgeons, with the aim of understanding professional identity construction within a specific group of residents.

METHOD

Using a grounded theory method, the authors collected data from 16 postgraduate surgeons through interviews. They complemented these initial interview data with ethnographic observations and additional descriptive interviews to explore the attitudes and values learned by surgeons during residency training (2010-2013). The participants were attending surgeons and residents in a general surgical training program in a university teaching hospital in the United Kingdom.

RESULTS

Participating surgeons described learning personal values or attitudes that they regarded as core to "becoming a surgeon" and key to professional identity construction. They described learning to be a perfectionist, to be accountable, and to self-manage and be resilient. They discussed learning to be self-critical, sometimes with the unintended consequence of seeming neurotic. They described learning effective teamwork as well as learning to take initiative and be innovative, which enabled them to demonstrate leadership and drive actions and agendas forward within the health care organization where they worked.

CONCLUSIONS

To the authors' knowledge, this is the first study to systematically explore the learning of professional identity amongst postgraduate surgeons. The study contributes to the literature on professional identity construction within medical education. The authors conclude that the demise of the apprenticeship model and the rise of duty hours limitations may affect not only the acquisition of technical skills but, more important, the construction of surgeon professional identity.

Possibility and agency in Figured Worlds: becoming a 'good doctor'

CONTEXT

Figured Worlds is a socio-cultural theory drawing on Vygotskian and Bakhtinian traditions, which has been applied in research into the development of identities of both learners and teachers in the wider education literature. It is now being adopted in medical education.

OBJECTIVE

The objective of this paper is to show what Figured Worlds can offer in medical education. Having explained some of its central tenets, we apply it to an important tension in our field.

METHODS

The assumption that there is a uniform 'good doctor' identity, which must be inculcated into medical students, underlies much of what medical educators do, and what our regulators enforce. Although diversity is encouraged when students are selected for medical school, pressure to professionalise students creates a drive towards a standardised professional identity by graduation. Using excerpts from reflective pieces written by two junior medical students, we review the basic concepts of Figured Worlds and demonstrate how it can shed light on the implications of this tension. Taking a Bakhtinian approach to discourse, we show how Adam and Sarah develop their professional identities as they negotiate the multiple overlapping and competing ways of being a doctor that they encounter in the world of medical practice. Each demonstrates agency by 'authoring' a unique identity in the cultural world of medicine, as they appropriate and re-voice the words of others.

DISCUSSION

Finally, we consider some important areas in medical education where Figured Worlds might prove to be a useful lens: the negotiation of discourses of gender, sexuality and social class, career choice as identification within specialty-specific cultural worlds, and the influence of hidden and informal curricula on doctor identity.

Professionalism, professionalization, expertise and compassion: a qualitative study of medical residents

BACKGROUND

Formal and informal medical curricula convey expectations about professionalization, that is, the development of physician identity, and also about professionalism. This study examined whether, in general, junior residents experienced any dissonance between these roles and focused particularly on how they negotiated conflicts between compassion, self-care, duty and medical expertise.

METHODS

In 2015, purposive sampling was used to select 21 first-year residents at a Canadian medical school. Participants listened to a 5-min audio-recording narrated in either male or female voice. Facing compassion fatigue after three obstetrical disasters over less than 2 days the resident narrator asks to go home. Participants reacted in writing to questions about this request and relevant teaching/modelling. Responses were analyzed using a qualitative, exploratory, thematic research design.

RESULTS

Four themes were identified: i) empathy, self-doubt and fear of weakness, ii) the need for support from and communication with physicians and others, iii) education received, and iv) professionalization outranks professionalism. Participants agreed that under the circumstances the narrator's care, compassion and request were appropriate. Never the less, many grappled with feeling that asking to be relieved of work demonstrated weakness and a shirking of responsibility. Respondents had received no formal teaching about balancing compassion for patients or self with professional duty. Preceptors' informal teaching and modeling valorized scientific disengagement above all else. What emerged was participants' drive to become detached clinicians who set aside emotional responses and interactions that could impede and be incompatible with professionalization. However, participants also recognized and lamented what was lost in such a transformation.

CONCLUSION

In the transition from student to practitioner, trainees' views and the modeling they receive shift emotion and compassion, whether for self or patients, from assets to liabilities as they aim to be invincible medical experts.

Dealing with emotions: medical undergraduates' preferences in sharing their experiences

CONTEXT

Patient care evokes emotional responses such as uncertainty, grief and pride in medical students. There is a need for opportunities to share and express such emotions because they influence students' professional development and well-being. There is a trend towards introducing mentor programmes into medical curricula. It remains unknown whether students are willing and able to share their emotional experiences within this formal setting. We set out to explore how medical students share their emotional experiences and why.

METHODS

We used thematic analysis, including purposeful sampling, parallel processes of data collection and constant comparative analysis, maintaining an audit trail for validation purposes. The study had a constructivist, interactional design and used Goffman's dramaturgical theory as an interpretive framework. Nineteen students participated in individual, semi-structured interviews.

RESULTS

Participants' narratives revealed a preference for sharing emotional experiences away from people who might expect them to uphold formal behaviour. They deliberately decided with whom to share their emotional experiences. Participants had a preference to talk to fellow students working in the same department, or family and friends outside medical school.

CONCLUSIONS

Participants found it difficult to uphold behaviours that they thought patients, preceptors or the organisation expected of them as future doctors. In adjusting their behaviour to meet those expectations, they became attuned to how to best present themselves based on the people present. This influenced how they chose which emotional experiences to share with whom.

What supervisors say in their feedback: construction of CanMEDS roles in workplace settings

The CanMEDS framework has been widely adopted in residency education and feedback processes are guided by it. It is, however, only one of many influences on what is actually discussed in feedback. The sociohistorical culture of medicine and individual supervisors' contexts, experiences and beliefs are also influential. Our aim was to find how CanMEDS roles are constructed in feedback in a postgraduate curriculum-in-action. We applied a set of discourse analytic tools to written feedback from 591 feedback forms from 7 hospitals, including 3150 feedback comments in which 126 supervisors provided feedback to 120 residents after observing their performance in authentic settings. The role of Collaborator was constructed in two different ways: a cooperative discourse of equality with other workers and patients; and a discourse, which gave residents positions of power-delegating, asserting and 'taking a firm stance'. Efficiency-being fast and to the point emerged as an important attribute of physicians. Patients were seldom part of the discourses and, when they were, they were constructed as objects of communication and collaboration rather than partners. Although some of the discourses are in line with what might be expected, others were in striking contrast to the spirit of CanMEDS. This study's findings suggest that it takes more than a competency framework, evaluation instruments, and supervisor training to change the culture of workplaces. The impact on residents of training in such demanding, efficiency-focused clinical environments is an important topic for future research.

Amending Miller's Pyramid to Include Professional Identity Formation

In 1990, George Miller published an article entitled "The Assessment of Clinical Skills/Competence/Performance" that had an immediate and lasting impact on medical education. In his classic article, he stated that no single method of assessment could encompass the intricacies and complexities of medical practice. To provide a structured approach to the assessment of medical competence, he proposed a pyramidal structure with four levels, each of which required specific methods of assessment. As is well known, the layers are "Knows," "Knows How," "Shows How," and "Does." Miller's pyramid has guided assessment since its introduction; it has also been used to assist in the assessment of professionalism.The recent emphasis on professional identity formation has raised questions about the appropriateness of "Does" as the highest level of aspiration. It is believed that a more reliable indicator of professional behavior is the incorporation of the values and attitudes of the professional into the identity of the aspiring physician. It is therefore proposed that a fifth level be added at the apex of the pyramid. This level, reflecting the presence of a professional identity, should be "Is," and methods of assessing progress toward a professional identity and the nature of the identity in formation should be guided by currently available methods.