Changes in wellbeing and professional values among medical undergraduate students: a narrative review of the literature

Warning: medical education is hazardous to your mental health. Medical students should make an informed decision to begin and continue training

For decades there has been ample evidence that training to become a physician and practicing medicine is hazardous to one's health and wellness. In the face of the extremely high rates of suicide, substance abuse, depression and burnout in the medical student, resident, and physician populations, it would be dishonest to suggest medical education and practice is all gain and no pain. This article is directed to members of the medical education community and challenges stakeholders to view their teaching and training of medical students as an intervention requiring free and informed consent. We hope this exercise shifts the paradigm of educators and enables students to enter medical training from a free and informed position.

Training for Professional Uncertainty: Socialization of Medical Students Through the Residency Application Process

PURPOSE

Uncertainty in medical decision making is a well-described phenomenon, and numerous scholars have acknowledged and illustrated the process of training medical students to grapple with this aspect of medical practice. While clinical uncertainty has been defined previously, medical trainees face additional forms of uncertainty beyond the clinical setting that have not, as yet, been investigated empirically. One area in which uncertainty can manifest outside of the clinical setting is during professional development. Medical students face substantial stress and ambiguity throughout their training, with the residency application period representing a culmination of these pressures. Here, the authors examined medical students' experiences during the residency application period and used these findings to define training for professional uncertainty.

METHOD

In 2018-2019, 6 focus groups of fourth-year medical students were conducted exploring students' experiences during the residency application period, including but not limited to Step 2 Clinical Knowledge, away rotations, and securing letters of recommendation. The authors then used constructivist, phenomenological methods to analyze participant responses.

RESULTS

Students frequently discussed challenges they faced during the residency application period. From these conversations, 2 themes were identified: (1) professional uncertainty related to career-based advice, which resulted from mixed messaging and inadequate information, and (2) professional uncertainty related to competing responsibilities, which students experienced when determining how to allocate a limited amount of time to multiple conflicting forces.

CONCLUSIONS

These results were used to define a novel concept-training for professional uncertainty. By navigating the residency application process, students learned to face various facets of professional uncertainty that they will continue to face throughout their careers. Since uncertainty can have many negative effects, including declining performance and burnout, defining professional uncertainty and training students to grapple with it is necessary to maximize their success throughout their careers.

'I found myself a despicable being!': Medical students face disturbing moral dilemmas

CONTEXT

The psychological realm of medical students' moral experiences is explored tangentially in medical education literature, often in the context of ethics or professionalism education. This study deepens our understanding by (a) investigating the nature of moral dilemmas experienced at the onset of clinical practice, (b) exploring students' emotional response to these dilemmas, and (c) examining how students perceive the influence of these dilemmas on their professional development.

METHODS

This is a cross-sectional qualitative study carried out in 2017 that applied thematic template analysis to individual interviews performed with last-year medical students. The interviews followed the drawing of a Rich Picture representing moral dilemmas experienced by medical students at the onset of clinical practice.

RESULTS

Moral dilemmas have four intertwined dimensions. The first relates to students' struggle to prioritise, balance and apply conflicting moral values; the second comprises the clash between students' inner motivation and the external constraints that limit the moral action; the third refers to the conflict between students' current attitudes with the desired/idealised attitudes of the doctor they intend to become; and the fourth corresponds to weighting conflicting ethical principles during the moral decision. Students' emotional responses are intense and long-lasting, and with a remarkable residue effect, particularly when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both detachment and growth in moral courage.

CONCLUSION

Moral dilemmas are memorable, complex and emotionally intense experiences that impact the professional development of medical students. Understanding students' moral dilemmas can help educators to devise pedagogical activities to anticipate and reflect on these experiences. These activities should happen under the guidance of a non-judgemental facilitator, capable of listening and legitimating students' thoughts and feelings while providing insights to nurture their professional development.

Mental Strength and Challenges among Thai Medical Students in Their Clinical Years-Study Protocol

(1) Background: Mental well-being and mental health problems are both important, especially among medical students who will be future doctors. The proposed study aimed to explore both positive and negative mental health experiences, especially mistreatment, occurring among medical students in their clinical years. (2) Methods/design: The study will conduct a cross-sectional survey between January 2021 and December 2021, among medical students studying in their clinical years across 23 medical schools throughout Thailand. Measurements regarding character strengths related to medical professionalism as well as other positive mental health strengths and negative mental health problems, e.g., anxiety, depression and experience of mistreatment will be completed. Both medical students and faculty members will be invited to participate in the study. (3) Discussion: this survey will provide an overall picture of medical students' mental well-being, positive and negative aspects of mental health and the magnitude of mistreatment and perspectives they experience. The limitations of the survey will be discussed.

'When They Struggle, I Cannot Sleep Well Either': Perceptions and Interactions Surrounding University Student and Teacher Well-Being

A wealth of evidence has indicated that both students and teachers experience high levels of stress, burnout, and ultimately compromised well-being in the university context. Although numerous studies have investigated well-being among university students, and other studies have addressed well-being among university teachers, these lines of research are often conducted in isolation from one another. This is surprising, as the importance of considering reciprocal links between students and teachers has been suggested in several empirical studies. Additionally, when researching well-being in academia, the conceptualizations tend to differ from study-to-study. The present research therefore investigated how students and teachers conceptualize well-being at the university based on their personal experiences, as well as how student and teacher well-being interact. To examine this, six university students (50% female), and ten teachers (50% female) from Germany and the Netherlands participated in semi-structured interviews. Qualitative analysis using a multistage coding process revealed detailed insights concerning students' and teachers' perceptions of well-being that coincided with positive psychology, resilience, multifaceted, and basic psychological need fulfillment approaches. Moreover, an interaction between students' and teachers' well-being became apparent, including several factors such as the student-teacher relationship that in turn, contributed to both population's well-being. The present findings lend evidence toward a more coherent conceptualization of well-being and are discussed in terms of suggestions for initiatives that simultaneously support both populations, for example, through the student-teacher relationship.

Group mentorship for undergraduate medical students-a systematic review

INTRODUCTION

Mentoring has become a prevalent educational strategy in medical education, with various aims. Published reviews of mentoring report very little on group-based mentorship programs. The aim of this systematic review was to identify group-based mentorship programs for undergraduate medical students and describe their aims, structures, contents and program evaluations. Based on the findings of this review, the authors provide recommendations for the organization and assessment of such programs.

METHODS

A systematic review was conducted, according to PRISMA guidelines, and using the databases Ovid MEDLINE, EMBASE, PsycINFO and ERIC up to July 2019. Eight hundred abstracts were retrieved and 20 studies included. Quality assessment of the quantitative studies was done using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

The 20 included studies describe 17 different group mentorship programs for undergraduate medical students in seven countries. The programs were differently structured and used a variety of methods to achieve aims related to professional development and evaluation approaches. Most of the studies used a single-group cross-sectional design conducted at a single institution. Despite the modest quality, the evaluation data are remarkably supportive of mentoring medical students in groups.

DISCUSSION

Group mentoring holds great potential for undergraduate medical education. However, the scientific literature on this genre is sparse. The findings indicate that group mentorship programs benefit from being longitudinal and mandatory. Ideally, they should provide opportunities throughout undergraduate medical education for regular meetings where discussions and personal reflection occur in a supportive environment.

Uncertainty in Decision Making in Medicine: A Scoping Review and Thematic Analysis of Conceptual Models

PURPOSE

The practice of medicine is rarely straightforward. Data used to facilitate medical decision making may be conflicting, ambiguous, or scarce, and providing optimal care requires balancing clinicians' expertise and available evidence with patients' preferences. To explore uncertainty in decision making across disciplines, the authors performed a scoping review and thematic analysis of the literature to formulate a model describing the decision-making process in medicine under uncertain conditions.

METHOD

In 2016, the authors performed a comprehensive search of key databases using a combination of keywords and controlled vocabulary. They identified and reviewed 3,398 records. After applying their inclusion and exclusion criteria to the titles and abstracts and then full texts, 19 articles were selected. The authors applied a qualitative thematic analysis to these articles, using codes to extract themes related to uncertainty in decision making.

RESULTS

The 19 articles spanned 6 fields of study and 5 disciplines within the health sciences. The thematic analysis revealed 6 main themes: recognition of uncertainty, classification of uncertainty, stakeholder perspectives, knowledge acquisition, decision-making approach, and evaluation of the decision-making process.

CONCLUSIONS

Based on the themes that emerged from their thematic analysis of the literature characterizing the effects of uncertainty and ambiguity on the decision-making process, the authors developed a framework depicting the interplay between these themes with a visual representation of the decision-making process under uncertain conditions. Future research includes further development and validation of this framework to inform medical school curricula.

An Exploration of Medical Education in Central and Southern China: Measuring the Professional Competence of Clinical Undergraduates

Background: The cultivation and assessment of the professional competence of clinical undergraduates is essential to medical education. This study aimed to construct a scale to evaluate the professional competence of clinical undergraduates as well as its determinants. Methods: The competence scale was developed on the basis of four medical education standards, the literature, and expert interviews. A total of 288 undergraduates from two types of medical colleges in central and southeastern China were selected by a multistage sampling strategy. Factor analysis, correlation analysis, and internal consistency reliability were used to verify the validity and reliability of the scale. Results: A scale consisting of eight factors with 51 items was determined for factor analysis. Cronbach’α coefficients among the eight dimensions were over 0.800, with mean scores of 1.76, 1.38, 1.92, 1.54, 1.77, 1.25, 1.60, and 2.34. Clinical undergraduates with above average academic grades achieved a higher score in essential clinical knowledge (p < 0.05) and better professionalism was reported among females (p < 0.05). Conclusion: The competence scale showed excellent reliability and validity. Respondents in this study showed a moderate level of professional competence. This study could be a reference for medical educators and policy makers in order to improve medical education standards for clinical undergraduates in China and other countries with similar settings.

Accounting for complexity in medical education: a model of adaptive behaviour in medicine

CONTEXT

Medicine is practised in complex systems. Physicians engage in clinical and operational problems that are dynamic and lack full transparency. As a consequence, the behaviour of medical systems and diseases is often unpredictable. Medical science has equipped physicians with powerful tools to favourably impact health, but a reductionist approach alone is insufficient to optimally address the complex challenges posed by illness and public health. Concepts from complexity science, such as continuous quality improvement and teamwork, strive to fill the gap between biomedical knowledge and the realities of practice. However, the superficial treatment of these systems-thinking concepts in medical education has distorted their implementation and undermined their impact. 'Systems thinking' has been conflated with 'systematic thinking'; concepts which are adaptive in nature are being taught as standardised, reductionist tools.

METHODS

Using concepts from complexity science, the history of science and psychology, this problem is outlined and a theoretical model of professional development is proposed.

RESULTS

This model proposes that complex problem solving and adaptive behaviour, not technical expertise, are distinguishing features of professionalism.

DISCUSSION

The impact of this model on our understanding of physician autonomy, professionalism, teamwork and continuous quality improvement is discussed. This model has significant implications for the structure and content of medical education. Strategies for enhancing medical training, including interventions in recruitment, the curriculum and evaluation, are reviewed. Such adjustments would prepare trainees to more effectively utilise biomedical knowledge and tools in the complex high-stakes reality of medical practice.

International study of medical school learning environments and their relationship with student well-being and empathy

OBJECTIVE

To assess whether favourable perceptions of the learning environment (LE) were associated with better quality of life, less burnout and more empathy across three undergraduate medical education programmes in Israel, Malaysia and China.

METHODS

Cross-sectional surveys were administered at the end of the 2013-2014 academic year at three medical schools: Technion American Medical Students Program (TAMS) in Israel, Perdana University-Royal College of Surgeons in Ireland School of Medicine (PURCSI) in Malaysia and Peking Union Medical College (PUMC) in China. LE perceptions were assessed using the Johns Hopkins Learning Environment Scale (JHLES). Well-being was assessed using validated items for quality of life and the depersonalisation and emotional exhaustion domains of burnout. The 20-item Jefferson Empathy Scale assessed empathy. Statistical analyses included bivariate regressions and multivariate regressions that adjusted for gender, school, class year and perceived academic rank.

RESULTS

Overall, 400/622 (64.3%) students responded, with the following rates by site: TAMS 92/121 (76.0%), PURCSI 160/198 (80.1%) and PUMC 148/303 (48.8%). In multivariate models, favourable overall LE perceptions were associated with higher odds of good quality of life (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.8-5.8; p < 0.001) and lower odds of emotional exhaustion (OR, 0.34; 95% CI, 0.24-0.50; p < 0.001) and depersonaliation (OR, 0.30; 95% CI, 0.24-0.37; p = 0.001). 'Community of Peers', one of seven factors in the JHLES, was the only one to be independently associated with better quality of life and less emotional exhaustion and depersonalisation. After adjusting for covariates, there was not a statistically significant association between overall LE and empathy (OR, 1.4; 95% CI, 0.91-2.2; p = 0.12).

CONCLUSIONS

Students' LE perceptions are closely associated with their well-being, and fostering peer community may hold promise for enhancing quality of life and protecting against burnout. Across these three settings, LE and empathy were not closely related, suggesting that any influence of learning environment on empathy would be modest.