Trustworthiness and Professionalism in Academic Medicine

Explaining needs for rehabilitation in patients with bone sarcoma and a megaprosthesis: a qualitative, grounded theory study

PURPOSE

To explain the needs for rehabilitation of patients with bone sarcoma before and after surgical resection and reconstruction with megaprosthesis.

MATERIALS AND METHODS

We performed a qualitative study following constructivist grounded theory principles. We purposefully recruited rich cases. Data were collected using semi-structured interviews and analyzed with grounded theory data-analysis. Initial, focused, and theoretical coding were first performed independently by two authors and followed by discussion in consensus meetings with all authors. Ultimately, a conceptual model was created.

RESULTS

Thirteen participants were interviewed between March and May 2023. Seven theoretical codes were found. The first is the need to achieve a new normal, being able to function with their medical history and megaprosthesis in a new normal life. Two key values patients needed were being understood and being prepared. Four important conditions that patients needed were: optimal conditions for rehabilitation, a trustworthy physical therapist, a clear closure from rehabilitation, and access to expertise in the hospital. The core category was achieving a new normal.

CONCLUSIONS

Patients with bone sarcoma need rehabilitation to achieve a new normal life. With the understanding of needs regarding rehabilitation now gained, the care for patients with bone sarcoma should be better tailored.

Reflections from Chinese and Japanese Physicians on Medical Disputes

Physician-patient disputes are a major problem in healthcare. Physician-patient conflicts, workplace violence, and direct involvement in disputes have a significant negative impact on the well-being of physicians. China and Japan have similar cultures but differing healthcare systems. The present study aimed to examine and compare the experiences and perceptions of Chinese and Japanese physicians regarding medical disputes. Qualitative descriptive content analysis was performed for 18 cases from each country to assess the major issues involved in each case and their impact on the physicians. Common issues in medical disputes for both countries included monetary motives of patients and/or families, violence/threats from patients and/or families, the inability of patients and/or families to understand the risk of complications, and the uncertainties of medicine. The serious impact of medical disputes on the mental health and professionalism of physicians was also an issue shared by physicians of both countries. There were, however, differences in the magnitude and frequency of these issues between the two countries. Pre-existing distrust of physicians among patients and/or families was noted only by Chinese physicians, and insufficient information disclosure by physicians was noted only by Japanese physicians. In conclusion, there were similarities and differences between the two countries in the perceptions of physicians regarding medical disputes. Our analysis revealed differing healthcare situations due to cultural and institutional differences as well as universal problems intrinsic to medicine. Based on our results, we propose several key principles to improve the physician-patient relationship.

Addressing Moral Distress After Dobbs v. Jackson Women's Health Organization : A Professional Virtues-Based Approach

ABSTRACT

The June 2022 U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization abolished federal protections for reproductive choice. In states where subsequent legislation has restricted or banned access to abortion services, physicians and trainees are prevented from providing ethically justified evidence-based care when patients with previable pregnancies are seeking an abortion. Pregnant patients' vulnerabilities, stress, and the undue burden that they experience when prevented from acting in accordance with their reproductive decision-making can evoke negative emotional consequences, including moral distress in clinicians. Moral distress occurs when clinicians feel a moral compulsion to act a certain way but cannot do so because of external constraints, including being hindered by state laws that curtail practicing in line with professional standards on reproductive health care. Moral distress has the potential to subvert prudent clinical judgment. The authors provide recommendations for managing moral distress in these circumstances based on the professional virtues. The fundamental professional virtues of integrity, compassion, self-effacement, self-sacrifice, and humility inform the management of moral distress and how to respond thoughtfully and compassionately, without over-identification or indifference to the plight of patients denied abortions. The authors also discuss the role of academic leaders and medical educators in cultivating a virtue-based professional culture at the forefront of clinical and educational processes in a post- Dobbs world.

Virtues in Competency-Based Assessment Frameworks: A Text Analysis

Introduction

Official documentation of specialty training provides comprehensive and elaborate criteria to assess residents. These criteria are commonly described in terms of competency roles and entrustable professional activities (EPA's), but they may also implicitly encompass virtues. Virtues are desirable personal qualities that enable a person, in this case, a medical specialist, to make and act on the right decisions. We articulate these virtues and explore the resulting implied ideal of a medical professional.

Method

We applied a two-staged virtue ethical content analysis to analyze documents, specific to the Dutch training program of the Ear, Nose, and Throat (ENT) specialty. First, we identified explicit references to virtues. Next, we articulated implicit virtues through interpretation. The results were categorized into cardinal, intellectual, moral, and professional virtues.

Results

Thirty virtues were identified in the ENT- training program. Amongst them, practical wisdom, temperance, and commitment. Furthermore, integrity, curiosity, flexibility, attentiveness, trustworthiness and calmness are often implicitly assumed. Notable findings are the emphasis on efficiency and effectiveness. Together, these virtues depict an ideal of a future medical specialist.

Conclusion

Our findings suggest that competency-frameworks and EPA's implicitly appeal to virtues and articulate a specific ideal surgeon. Explicit attention for virtue development and discussion of the role and relevance of implied ideal professionals in terms of virtues could further improve specialty training.

Professional virtue of civility and the responsibilities of medical educators and academic leaders

Incivility among physicians, between physicians and learners, and between physicians and nurses or other healthcare professionals has become commonplace. If allowed to continue unchecked by academic leaders and medical educators, incivility can cause personal psychological injury and seriously damage organisational culture. As such, incivility is a potent threat to professionalism. This paper uniquely draws on the history of professional ethics in medicine to provide a historically based, philosophical account of the professional virtue of civility. We use a two-step method of ethical reasoning, namely ethical analysis informed by pertinent prior work, followed by identifying the implications of clearly articulated ethical concepts, to meet these goals. The professional virtue of civility and the related concept of professional etiquette was first described by the English physician-ethicist Thomas Percival (1740-1804). Based on a historically informed philosophical account, we propose that the professional virtue of civility has cognitive, affective, behavioural and social components based on a commitment to excellence in scientific and clinical reasoning. Its practice prevents a dysfunctional organisational culture of incivility and sustains a civility-based organisational culture of professionalism. Medical educators and academic leaders are in a pivotal and powerful position to role model, promote and inculcate the professional virtue of civility as essential to an organisational culture of professionalism. Academic leaders should hold medical educators accountable for discharge of this indispensable professional responsibility.

Enculturating a Community of Action: Health Professions Educators' Perspectives on Teaching With Wikipedia

PURPOSE

Health professions educators are increasingly called on to engage learners in more meaningful instruction. Many have used Wikipedia to offer an applied approach to engage learners, particularly learning related to evidence-based medicine (EBM). However, little is known about the benefits and challenges of using Wikipedia as a pedagogic tool from the collective experience of educators who have sought to improve their instructional practice with it. This study aims to synthesize the perspectives of health professions education (HPE) instructors on the incorporation of Wikipedia editing into their HPE courses.

METHOD

Applying a constructivist approach, the authors conducted semistructured interviews from July to December 2020, with 17 participating HPE instructors who had substantively integrated Wikipedia into their curriculum at 13 institutions. Participants were interviewed about their experiences of integrating Wikipedia editing into their courses. Thematic analysis was conducted on resulting transcripts.

RESULTS

The authors observed 2 broad themes among participants' expressed benefits of teaching with Wikipedia. First, Wikipedia provides a meaningful instructional alternative that also helps society and develops learners' information literacy and EBM skills. Second, Wikipedia supports learners' careers and professional identity formation. Identified challenges included high effort and time, restrictive Wikipedia sourcing guidelines, and difficult interactions with stakeholders.

CONCLUSIONS

Findings build on known benefits, such as providing a real-world collaborative project that contextualizes students' learning experiences. They also echo known challenges, such as the resource-intensive nature of teaching with Wikipedia. The findings of this study reveal the potential of Wikipedia to enculturate HPE students within a situated learning context. They also present implications for HPE programs that are considering implementing Wikipedia and faculty development needed to help instructors harness crowd-sourced information tools' pedagogic opportunities as well as anticipate their challenges.

The Relationship Between Professionalism and Leadership: Parent-Child or Sibling?

Professionalism has been the foundation of physical therapy's contract with society, with the American Physical Therapy Association's (APTA) Core Values and Code of Ethics serving as its building blocks. Professional formation has focused on professionalism and has been taught in a manner that is more implicit than explicit in doctor of physical therapy (DPT) curricula. As a domain of competence, professionalism alone has not been broad enough to meet societal needs. In reaching our centennial year, many have reflected on what competencies are needed to move forward. The need for leadership competencies is not new and has been espoused by our leaders over the past 100 years. Some advocate for the adoption of leadership as a unique domain of competence, separate from the domain of professionalism, whereas others propose that either professionalism or leadership is one domain of competence that subsumes the other. The purpose of this Perspective is twofold: to compare and contrast the concepts of professionalism and leadership, and to make recommendations regarding what constitutes domains of competence within the professional formation of physical therapists. This Perspective offers recommendations addressing professional formation and the adoption of leadership and professionalism as 2 distinct domains of competence and discusses educational and clinical implications of the recommendations. This Perspective asserts that these recommendations must be adopted to move the profession forward into the next century so that physical therapists are recognized as adding value to the health care system and the evolving needs of society.

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.

How supervisor trust affects early residents' learning and patient care: A qualitative study

INTRODUCTION

Trust between supervisors and trainees mediates trainee participation and learning. A resident (postgraduate) trainee's understanding of their supervisor's trust can affect their perceptions of their patient care responsibilities, opportunities for learning, and overall growth as physicians. While the supervisor perspective of trust has been well studied, less is known about how resident trainees recognize supervisor trust and how it affects them.

METHODS

In this qualitative study, 21 pediatric residents were interviewed at a single institution. Questions addressed their experiences during their first post-graduate year (PGY-1) on inpatient wards. Each interviewee was asked to describe three different patient care scenarios in which they perceived optimal, under-, and over-trust from their resident supervisor. Data were analyzed using thematic analysis.

RESULTS

Residents recognized and interpreted their supervisor's trust through four factors: supervisor, task, relationship, and context. Optimal trust was associated with supervision balancing supervisor availability and resident independence, tasks affording participation in decision-making, trusting relationships with supervisors, and a workplace fostering appropriate autonomy and team inclusivity. The effects of supervisor trust on residents fell into three themes: learning experiences, attitudes and self-confidence, and identities and roles. Optimal trust supported learning via tailored guidance, confidence and lessened vulnerability, and a sense of patient ownership and team belonging.

DISCUSSION

Understanding how trainees recognize supervisor trust can enhance interventions for improving the dialogue of trust between supervisors and trainees. It is important for supervisors to be cognizant of their trainees' interpretations of trust because it affects how trainees understand their patient care roles, perceive autonomy, and approach learning.

Spirals of Sustainable Academic Motivation, Creativity, and Trust of Higher Education Staff

Sustainability has to penetrate more and more into higher education. It should not focus only on traditional elements. It should also enter new, but for future improvement, extremely important areas. Based on this premise, creativity and motivation, when additionally interconnected and supported by trust that is provided and achieved, decide on the progress and sustainability of universities. This connection is gaining importance especially from the point of view of building solid foundations and mechanisms that functionally preserve the potential effects of these elements in the future. For this reason and following the nature, importance, and content of sustainable academic motivation (SAM), the paper introduces two new concepts: sustainable academic creativity (SAC) and sustainable academic trust (SAT). For further original contributions, the paper hypothesizes the existence of mutual—spiral—relations of sustainable academic motivation (SAM), sustainable academic creativity (SAC), and sustainable academic trust (SAT). The empirical section tests the validity of this claim in the universities of two countries: the Slovak Republic and Poland. A survey performed on a sample of n=181 pedagogical, scientific, management, and administrative staff in higher education confirms the existence of these spirals. The results indicate the spiral effect of motivation when connected with creativity and trust and show that it is accented by the crucial principles of sustainability (responsibility, novelty, usefulness, progress, etc.). Therefore, the paper’s conclusion contains the explanations for the potential occurrence of three types of sustainably mutual systems and complexes. These are: (a) individual sustainable systems of SAM, SAC, and SAT; (b) group/sectional sustainable systems of SAM, SAC, and SAT; and (c) the global sustainable complex of SAM, SAC, and SAT in the university.

Assessment of dental residents' professionalism through Professionalism Mini-Evaluation Exercise (P-MEX)

PURPOSE/OBJECTIVES

The aim of the study was to assess the professional behavior of dental residents through Professionalism Mini-Evaluation Exercise (P-MEX).

METHODS

This was a descriptive-analytical study. Content validity of P-MEX form was investigated for use in the context of dentistry. A total of 24-item version of P-MEX consisted of doctor-patient relationship skills (n = 7), reflective skills (n = 5), time management (n = 3), and interprofessional relationship skills (n = 9) was used in the present study. Residents in different dental specialties (n = 56) were evaluated by trained raters (448 times). Data were analyzed by descriptive (mean, SD) and analytical tests (Pearson, ANOVA, and post hoc test (Bonferroni)).

RESULTS

Validity of P-MEX was approved in the field of dentistry. The mean score of professional behavior in residents were reported 2.79 ± 0.24, with minimum and maximum scores of 2.17 and 3.62, respectively. The residents' professional behavior in the domain of reflective skills and doctor-patient relationship skills were lower than the other domains.

CONCLUSION(S)

The results showed that the scores of professional behavior among dental residents were classified in the below expectation level and their scores have followed a downward trend from the second year. Therefore, planning for training and continuous assessment of professional behavior among residents in the faculty of dentistry should be considered.

Teaching Professional Formation in Response to the COVID-19 Pandemic

In response to the COVID-19 pandemic, the Association of American Medical Colleges has called for a temporary suspension of clinical teaching activities for medical students. Planning for the continued involvement of learners in patient care during this pandemic should include teaching learners professional formation. The authors provide an ethical framework to guide such teaching, based on the ethical principle of beneficence and the professional virtues of courage and self-sacrifice from professional ethics in medicine. The authors show that these concepts support the conclusion that learners are ethically obligated to accept reasonable, but not unreasonable, risk. Based on this ethical framework, the authors provide an account of the process of teaching professional formation that medical educators and academic leaders should implement. Medical educators and academic leaders should embrace the opportunity that the COVID-19 pandemic presents for teaching professional formation. Learners should acquire the conceptual vocabulary of professional formation. Learners should recognize that risk of infection from patients is unavoidable. Learners should become aware of established ethical standards for professional responsibility during epidemics from the history of medicine. Learners should master understandable fear. Medical educators and academic leaders should ensure that didactic teaching of professional formation continues when it becomes justified to end learners' participation in the processes of patient care; topics should include the professionally responsible management of scarce medical resources. The COVID-19 pandemic will not be the last major infectious disease that puts learners at risk. Professional ethics in medicine provides powerful conceptual tools that can be used as an ethical framework to guide medical educators to teach learners, who will bear leadership responsibilities in responses to future pandemics, professional formation.