The Hidden Curriculum of Compassionate Care: Can Assessment Drive Compassion?

Integrating expert patients perspectives on the processes of engaging them in early medical education

In the practice of healthcare, a new paradigm has emerged that perhaps challenges traditional notions of patient-clinician relationships. This shift involves recognising the invaluable role of expert patients, individuals who possess first-hand experience of life with their specific health conditions or chronic illnesses. These individuals have gained deep practical insights, knowledge, and coping strategies through their personal journeys. Modern healthcare practice focusing on individualised care necessitates that patients and their experiences become integral to the education of future healthcare professionals, from the start of their learning journeys, steering us toward more compassionate and person-centred approaches. This communication article underscores the importance of developing structured, coordinated programs that involve patients in curriculum design, implementation, and evaluation. By fostering authentic partnerships, medical education can create richer learning environments that promote compassionate care and better prepare future healthcare professionals. Ultimately, embracing patient perspectives as integral to the educational process is essential for improving healthcare delivery and outcomes.

The development of a marker system for Pharmacists' Behavioural Skills

OBJECTIVES

Pharmacists increasingly require complex behavioural skills to fulfil enhanced roles within healthcare teams. Behavioural marker systems are used to assess behavioural (or non-technical) skills during immersive simulation. This study aimed to develop a marker system for pharmacists' behavioural skills in patient-focussed care scenarios, and to investigate its content validity.

METHODS

Literature describing existing marker systems and the requisite behavioural skills of pharmacists were presented to two expert panels, alongside video examples of pharmacists in patient-focussed care simulations. The expert panels used this information to develop a new behavioural marker system. A third expert panel assessed the content validity, and the item- and scale-content validity indices were calculated.

KEY FINDINGS

The resulting tool contains four categories, each with three or four skill elements: situation awareness (gathering information; recognising and understanding information; anticipating, preparing and planning), decision-making and prioritisation (identifying options; prioritising; dealing with uncertainty; implementing or reviewing decisions), collaborative working (involving the patient; information sharing; leadership or followership), self-awareness (role awareness; speaking up; escalating care; coping with stress). The scale-content validity index was 0.95 (ideal) and the only item below the acceptable cut-off was 'leadership or followership' (0.7).

CONCLUSIONS

This tool is the first marker system designed to assess the behavioural skills of pharmacists in patient-focussed care scenarios. There is evidence of good content validity. It is hoped that once validated, the Pharmacists' Behavioural Skills marker system will enable pharmacy educators to provide individualised and meaningful feedback on simulation participants' behavioural skills.

How radiography educators teach the concept of caring to undergraduate radiography students

INTRODUCTION

Caring is a key part of a radiographers work and the education of student radiographers. Despite recent literature highlighting the importance of putting the patient at the centre of care and being caring, research describing the educational approaches used by radiography educators to facilitate the teaching of caring is lacking. The aim of this paper is to explore the teaching and learning strategies used by radiography educators to facilitate the development of caring in students.

METHODS

A qualitative, exploratory research design was used. Purposive sampling was used to select radiography educators (n = 9). This was followed by quota sampling to ensure all four radiography disciplines, namely diagnostic radiography, diagnostic ultrasound, nuclear medicine technology and radiation therapy were represented in the sample. Data was analysed thematically and themes were identified.

RESULTS

The findings indicated that radiography educators use teaching strategies such as peer role play, learning through observation and role modelling to facilitate teaching and learning of caring.

CONCLUSION

The study suggested that although radiography educators know the teaching strategies that facilitate caring, aspects such as clarification of professional values and the refinement of reflection seems to be lacking.

IMPLICATIONS FOR PRACTICE

The teaching and learning approaches that can assist students in developing as caring radiographers can add to the evidence-based pedagogies that shape the teaching of caring in the profession.

Teaching compassion for social accountability: A parallaxic investigation

BACKGROUND

In an arts integrated interdisciplinary study set to investigate ways to improve social accountability (SA) in medical education, our research team has established a renewed understanding of compassion in the current SA movement.

AIM

This paper explores the co-evolution of compassion and SA.

METHODS

The study used an arts integrated approach to investigate people's perceptions of SA in four medical schools across Australia, Canada, and the USA. Each school engaged approximately 25 participants who partook in workshops and in-depth interviews.

RESULTS

We began with a study of SA and the topic of compassion emerged out of our qualitative data and biweekly meetings within the research team. Content analysis of the data and pedagogical discussion brought us to realize the importance of compassion in the practice of SA.

CONCLUSIONS

The cultivation of compassion needs to play a significant role in a socially accountable medical educational system. Medical schools as educational institutions may operate themselves with compassion as a driving force in engaging partnership with students and communities. Social accountability without compassion is not SA; compassion humanizes institutional policy by engaging sympathy and care.

Student perspectives on programmatic assessment in a large medical programme: A critical realist analysis

BACKGROUND

Fundamental challenges exist in researching complex changes of assessment practice from traditional objective-focused 'assessments of learning' towards programmatic 'assessment for learning'. The latter emphasise both the subjective and social in collective judgements of student progress. Our context was a purposively designed programmatic assessment system implemented in the first year of a new graduate entry curriculum. We applied critical realist perspectives to unpack the underlying causes (mechanisms) that explained student experiences of programmatic assessment, to optimise assessment practice for future iterations.

METHODS

Data came from 14 in-depth focus groups (N = 112/261 students). We applied a critical realist lens drawn from Bhasker's three domains of reality (the actual, empirical and real) and Archer's concept of structure and agency to understand the student experience of programmatic assessment. Analysis involved induction (pattern identification), abduction (theoretical interpretation) and retroduction (causal explanation).

RESULTS

As a complex educational and social change, the assessment structures and culture systems within programmatic assessment provided conditions (constraints and enablements) and conditioning (acceptance or rejection of new 'non-traditional' assessment processes) for the actions of agents (students) to exercise their learning choices. The emergent underlying mechanism that most influenced students' experience of programmatic assessment was one of balancing the complex relationships between learner agency, assessment structures and the cultural system.

CONCLUSIONS

Our study adds to debates on programmatic assessment by emphasising how the achievement of balance between learner agency, structure and culture suggests strategies to underpin sustained changes (elaboration) in assessment practice. These include; faculty and student learning development to promote collective reflexivity and agency, optimising assessment structures by enhancing integration of theory with practice, and changing learning culture by both enhancing existing and developing new social structures between faculty and the student body to gain acceptance and trust related to the new norms, beliefs and behaviours in assessing for and of learning.

"Get the DNR": residents' perceptions of goals of care conversations before and after an e-learning module

BACKGROUND

Residents frequently lead goals of care (GoC) conversations with patients and families to explore patient values and preferences and to establish patient-centered care plans. However, previous work has shown that the hidden curriculum may promote physician-driven agendas and poor communication in these discussions. We previously developed an online learning (e-learning) module that teaches a patient-centered approach to GoC conversations. We sought to explore residents' experiences and how the module might counteract the impact of the hidden curriculum on residents' perceptions and approaches to GoC conversations.

METHODS

Eleven first-year internal medicine residents from the University of Toronto underwent semi-structured interviews before and after completing the module. Themes were identified using principles of constructivist grounded theory.

RESULTS

Prior to module completion, residents described institutional and hierarchical pressures to "get the DNR" (Do-Not-Resuscitate), leading to physician-centered GoC conversations focused on code status, documentation, and efficiency. Tensions between formal and hidden curricula led to emotional dissonance and distress. However, after module completion, residents described new patient-centered conceptualizations and approaches to GoC conversations, feeling empowered to challenge physician-driven agendas. This shift was driven by greater alignment of the new approach with their internalized ethical values, greater tolerance of uncertainty and complexity in GoC decisions, and improved clinical encounters in practice.

CONCLUSION

An e-learning module focused on teaching an evidence-based, patient-centered approach to GoC conversations appeared to promote a shift in residents' perspectives and approaches that may indirectly mitigate the influence of the hidden curriculum, with the potential to improve quality of communication and care.

John Gregory's medical ethics elucidates the concepts of compassion and empathy

PURPOSE

This paper draws on eighteenth-century British medical ethics to elucidate compassion and empathy and explains how compassion and empathy can be taught, to rectify their frequent conflation.

COMPASSION IN THE HISTORY OF MEDICAL ETHICS

The professional virtue of compassion was first described in eighteenth-century British medical ethics by the Scottish physician-ethicist, John Gregory (1724-1773) who built on the moral psychology of David Hume (1711-1776) and its principle of sympathy.

COMPASSION AND EMPATHY DEFINED

Compassion is the habitual exercise of the affective capacity to engage, with self-discipline, in the experience of the patient and therefore become driven to provide effective care for the patient. Empathy is the habitual exercise of the cognitive capacity to imagine the experience of patient and to have reasons to care for the patient. There are rare clinical circumstances in which empathy should replace compassion, for example, in responding to abusive patients. Because the abstract concepts of medical ethics are translated into clinical practice by medical educators, we identify the pedagogical implications of these results by setting out a process for teaching compassion and empathy.

THE TASK AHEAD

Eighteenth-century British medical ethics provides a clinically applicable, philosophical response to conflation of the moral virtue of compassion and the intellectual virtue of empathy and applying them clinically.

From Grading to Assessment for Learning: A Qualitative Study of Student Perceptions Surrounding Elimination of Core Clerkship Grades and Enhanced Formative Feedback

Problem: Medical students perceive honors grading during core clerkships as unfair and inequitable, and negatively impacting their learning and wellbeing. Eliminating honors grading, a powerful extrinsic motivator, and emphasizing formative feedback may address these problems and promote intrinsic motivation and learning. However, it is unknown how transitioning from honors to pass/fail grading with enhanced formative feedback in the core clerkship year may affect student learning experiences, wellbeing, and perceptions of the learning environment. Intervention: Core clerkship grading was transitioned from honors/pass/fail to pass/fail at one US medical school. In addition, the requirement for students to obtain formative supervisor feedback was formalized to twice per week. Context: This qualitative study utilized semi-structured interviews to explore the perceptions among core clerkship students of learning and assessment. Interview questions addressed motivation, wellbeing, learning behaviors, team dynamics, feedback, and student and supervisor attitudes regarding assessment changes. The authors analyzed data inductively using thematic analysis informed by sensitizing concepts related to theories of motivation (goal orientation theory and self-determination theory). Impact: Eighteen students participated, including five with experience in both honors-eligible and pass/fail clerkships. The authors identified three major themes in students' descriptions of the change in approach to assessment: student engagement in clerkships, wellbeing, and recognition of learning context. Student engagement subthemes included intrinsic motivation for patient care rather than performing; sense of agency over learning, including ability to set learning priorities, seek and receive feedback, take learning risks, and disagree with supervisors, and collaborative relationships with peers and team members. Positive wellbeing was characterized by low stress, sense of authenticity with team members, prioritized physical health, and attention to personal life. Learning context subthemes included recognition of variability of clerkship contexts with pass/fail grading mitigating fairness and equity concerns, support of the grading change from residents and some attendings, and implications surrounding future stress and residency selection. Lessons Learned: Students perceive a transition from honors grading to pass/fail with increased feedback as supporting their engagement in learning, intrinsic motivation, and wellbeing. Drivers of wellbeing appear to include students' feelings of control, achieved through the ability to seek learning opportunities, teaching, and constructive feedback without the perceived need to focus on impressing others. Ongoing evaluation of the consequences of this shift in assessment is needed.

Designing health professional education curricula using systems thinking perspectives

BACKGROUND

Medical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student's preparedness for practice.

METHODS

By framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media.

RESULTS

We describe how the 3P-6Cs toolkit captures a learner's personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students' developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions.

CONCLUSION

Applying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student's preparation for lifelong practice.

Medical student reflections: Chaplain shadowing as a model for compassionate care training

PURPOSE

Training of compassionate and empathetic physicians requires commitment by educators to make it a priority. Chaplains typically have time and training to effectively demonstrate compassionate care in the clinical setting. This qualitative study aims to explore perceived benefits among medical students from pastoral care shadowing in integrating compassion and spirituality into education curricula.

METHODS

Sixty-four written reflections from first- and second-year medical students were collected from December 2018 to January 2020 after shadowing with hospital chaplains. Unprompted reflections were analyzed using coding networks.

RESULTS

Four major themes identified included (1) learned values within pastoral care, (2) learned roles of pastoral care in the healthcare setting, (3) practiced spiritual assessment tools and resource identification, and (4) reflected personal impact on future career. Within each major theme, three to four sub-themes were further identified.

CONCLUSIONS

Reflections support chaplain shadowing as a model for emphasizing spiritual and compassionate care through role-modeling, hands-on learning and reflective practices.

Cultivating the joy of medicine: A focus on intrinsic factors and the meaning of our work

Physician burnout is at epidemic levels. In our role as healers, the concepts of humanism and relief of suffering are central themes in our work, yet burnout and depersonalization can threaten these values. While working to mitigate burnout, we need to move towards a focus on health and well-being and develop preventive strategies to cultivate resilience. This manuscript discusses the intrinsic factors that motivate us to be physicians: medicine as a calling, finding meaning in our work, and seeking joy in practice. Some strategies that enhance our resilience will be discussed including individual reflective practices, in addition to organizational strategies such as creating team mission statements, and participating in debriefing, Balint groups, and Schwartz Rounds. All of these practices provide opportunities to acknowledge the emotional impact of our care of patients and to focus on our values and the meaning of our work. Strategies to cultivate joy in practice are presented alongside a framework from the Institute for Healthcare Improvement to guide organizations.