1
|
Mccready G, Laperrière H. The advocacy process in Canadian community health nursing: A collaborative ethnography. J Adv Nurs 2024; 80:2847-2859. [PMID: 37837207 DOI: 10.1111/jan.15896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/09/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023]
Abstract
AIMS To shed light on the process of advocacy in the context of community health nursing, through a methodology inspired by the epistemologies of the South. DESIGN We conducted a collaborative ethnography in a community health centre in Canada. METHODS de Sousa Santos' epistemologies of the South, a typology of advocacy and main themes from historic research informed the methodology. Data were collected between 2016 and 2018 through 420 h of fieldwork observations and three group discussions, including a collective process to co-construct interpretations with participants. Twenty-one nurses participated in the study. RESULTS Nurses had sufficient work flexibility to practice advocacy actions focused on individuals and groups. They also engaged in attempts at policy reform in the form of defending access to appropriate care and changing the mode of care organization. However, these were curbed by bureaucracy and administrative rules, resulting in the eventual dismissal of health promotion actions and experiences of moral distress. CONCLUSION Despite the political climate of their work environment impeding social justice agendas, nurses' advocacy practices showed a persistence of moral values and ideals in coherence with the regional nursing legacy. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Acting at the organizational level and involving field nurses in decision making are potential avenues for increasing policy advocacy efficacy. IMPACT Examining contexts through another epistemic lens and methods of research drawing on history and anthropology has shed light on a process of advocacy. This research shows that organizations need to equip themselves with mechanisms to promote the sharing of realities between nurses, thereby building collective advocacy. REPORTING METHOD The research adheres to the EQUATOR guidelines with SRQR and COREQ methods. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
Collapse
Affiliation(s)
- Geneviève Mccready
- Health Science Department, University of Quebec at Rimouski, Rimouski, Quebec, Canada
| | | |
Collapse
|
2
|
Brown A, La J, Keri MI, Hillis C, Razack S, Korah N, Karpinski J, Frank JR, Wong B, Goldman J. In EPAs we trust, is quality and safety a must? A cross-specialty analysis of entrustable professional activity guides. MEDICAL TEACHER 2024:1-9. [PMID: 38527417 DOI: 10.1080/0142159x.2024.2323177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/21/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE The inclusion of quality improvement (QI) and patient safety (PS) into CanMEDS reflects an expectation that graduating physicians are competent in these areas upon training completion. To ensure that Canadian postgraduate specialty training achieves this, the translation of QI/PS competencies into training standards as part of the implementation of competency-based medical education requires special attention. METHODS We conducted a cross-specialty, multi-method analysis to examine how QI/PS was incorporated into the EPA Guides across 11 postgraduate specialties in Canada. RESULTS We identify cross-specialty variability in how QI/PS is incorporated, positioned, and emphasized in EPAs and milestones. QI/PS was primarily referenced alongside clinical activities rather than as a sole competency or discrete activity. Patterns were characterized in how QI/PS became incorporated into milestones through repetition and customization. QI/PS was also decoupled, conceptualized, and emphasized differently across specialties. CONCLUSIONS Variability in the inclusion of QI/PS in EPAs and milestones has important implications considering the visibility and influence of EPA Guides in practice. As specialties revisit and revise EPA Guides, there is a need to balance the standardization of foundational QI/PS concepts to foster shared understanding while simultaneously ensuring context-sensitive applications across specialties. Beyond QI/PS, this study illuminates the challenges and opportunities that lie in bridging theoretical frameworks with practical implementation in medical education, prompting broader consideration of how intrinsic roles and emergent areas are effectively incorporated into competency-based medical education.
Collapse
Affiliation(s)
- Allison Brown
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Julie La
- Graduate Program in Health Quality, Queen's University, Kingston, Canada
- Department of Surgery, Queen's University, Kingston, Canada
| | | | - Chris Hillis
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Saleem Razack
- Faculty of Medicine, University of British Columbia, Kelowna, Canada
| | - Nadine Korah
- Faculty of Medicine, McGill University, Montreal, Canada
| | | | - Jason R Frank
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Brian Wong
- Centre for Quality Improvement and Patient Safety, Toronto, Canada
- Faculty of Medicine, University of Toronto Temerty, Toronto, Canada
| | - Joanne Goldman
- Centre for Quality Improvement and Patient Safety, Toronto, Canada
- Faculty of Medicine, University of Toronto Temerty, Toronto, Canada
| |
Collapse
|
3
|
O'Rourke N, Outly A. Politics of Health Care Politics: A Call to Action. AACN Adv Crit Care 2024; 35:32-42. [PMID: 38457623 DOI: 10.4037/aacnacc2024123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
Nursing has been perceived as an apolitical profession. Although some advancements in legislation and political engagement for nursing have occurred, the perception remains; it is considered to be a relatively silent profession in the political and policy arenas. Authors, when trying to describe this phenomenon, have raised questions about whether the nursing profession is political. In addition, the motivation for participation and advocacy, as well as the barriers to these activities, have limited investigation, making it difficult to understand the real reasons behind nursing's political and policy immobility. The purpose of this article is to familiarize readers with politics, policy, and advocacy; levels of state and federal government; and the lawmaking process in different states. The goal is to offer information and identify factors that increase confidence and efficacy when engaging with the political system.
Collapse
Affiliation(s)
- Nancy O'Rourke
- Nancy O'Rourke is Adjunct Professor, Regis College, 235 Wellesley St, Weston, MA 02493
| | - Amanda Outly
- Amanda Outly is Student Success and Interlibrary Loan Librarian, Babson College, Babson Park, Massachusetts
| |
Collapse
|
4
|
Fazelipour M, Dhatt A, Sun T, Nemir A, Wilbur K. Pharmacy Students Practicing Health Advocate Competency Roles in Workplace-Based Training. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2023; 87:100118. [PMID: 37714657 DOI: 10.1016/j.ajpe.2023.100118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/25/2023] [Accepted: 04/05/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE Health advocacy competency roles are found in the educational outcomes of many health disciplines, yet their development is neglected in the professional curriculum and clinical learning environment. We explored how pharmacy students conceptualize health advocacy through their practice in workplace-based learning and any feedback they receive. METHODS We conducted a longitudinal diary study of Canadian pharmacy students completing Advanced Pharmacy Practice Experiences in hospital and community practices in their graduating year. At pre-determined intervals, 25 students recorded workplace-based activities they recognized as health advocacy and any feedback they received from supervisors, patients, or other staff. Written diary data from 180 records were analyzed by 5 researchers according to inductive content analysis steps and principles. RESULTS Pharmacy student records reflecting health advocacy roles were organized into 5 categories including, (1) disease prevention; (2) health promotion; (3) seamless care; (4) usual pharmacist care; and (5) professional advocacy. Although many activities were consistent with current competency role descriptions, they do not reflect educational outcomes associated with patient- or systems-level support necessary to address socio-political determinants of health. Although Advanced Pharmacy Practice Experience in training evaluation reports included scores for items related to health advocacy competency, few students confirmed receiving specific written or verbal feedback. CONCLUSION Pharmacy students construct health advocacy roles in workplace-based training through biomedical-oriented practices with little direct input offered by supervisors. Pharmacy educational outcomes require contemporary updates to health advocacy competency descriptions which offer examples for practical enactment at system-level and recommendations for feedback and assessment.
Collapse
Affiliation(s)
- Mojan Fazelipour
- The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Amninder Dhatt
- The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Tom Sun
- The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Arwa Nemir
- The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Kerry Wilbur
- The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada.
| |
Collapse
|
5
|
Mizumoto J, Mitsuyama T, Kondo S, Izumiya M, Horita S, Eto M. Defining the observable processes of patient care related to social determinants of health. MEDICAL EDUCATION 2023; 57:57-65. [PMID: 35953461 DOI: 10.1111/medu.14915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION An understanding of social determinants of health (SDH) and patients' social circumstances is recommended to deliver contextualised care. However, the processes of patient care related to SDH in clinical settings have not been described in detail. Observable practice activities (OPAs) are a collection of learning objectives and activities that must be observed in daily practice and can be used to describe the precise processes for professionals to follow in specific situations (process OPA.) METHODS: We used a modified Delphi technique to generate expert consensus about the process OPA for patient care related to SDH in primary care settings. To reflect the opinions of various stakeholders, the expert panel comprised clinical professionals (physicians, nurses, public health nurses, social workers, pharmacists and medical clerks), residents, medical students, researchers (medical education, health care, sociology of marginalised people), support members for marginalised people and patients. The Delphi rounds were conducted online. In Round 1, a list of potentially important steps in the processes of care was distributed to panellists. The list was modified, and one new step was added. In Round 2, all steps were acknowledged with few modifications. RESULTS Of 63 experts recruited, 61 participated, and all participants completed the Delphi rounds. A total of 14 observable steps were identified, which were divided into four components: communication, practice, maintenance and advocacy. The importance of ongoing patient-physician relationships and collaboration with professionals and stakeholders was emphasised for the whole process of care. DISCUSSION This study presents the consensus of a variety of experts on the process OPA for patient care related to SDHs. Further research is warranted to investigate how this Communication-Practice-Maintenance-Advocacy framework could affect medical education, quality of patient care, and patient outcomes.
Collapse
Affiliation(s)
- Junki Mizumoto
- Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshichika Mitsuyama
- Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Kondo
- Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masashi Izumiya
- Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shoko Horita
- Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masato Eto
- Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
6
|
Leep Hunderfund AN, Kumbamu A, O'Brien BC, Starr SR, Dekhtyar M, Gonzalo JD, Rennke S, Ridinger H, Chang A. "Finding My Piece in That Puzzle": A Qualitative Study Exploring How Medical Students at Four U.S. Schools Envision Their Future Professional Identity in Relation to Health Systems. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1804-1815. [PMID: 35797546 DOI: 10.1097/acm.0000000000004799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation. METHOD Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives. RESULTS Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences). CONCLUSIONS This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.
Collapse
Affiliation(s)
- Andrea N Leep Hunderfund
- A.N. Leep Hunderfund is associate professor of neurology and director, Learning Environment and Educational Culture, Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Ashok Kumbamu
- A. Kumbamu is assistant professor of biomedical ethics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Bridget C O'Brien
- B.C. O'Brien is professor of medicine and education scientist, Center for Faculty Educators, University of California, San Francisco, San Francisco, California
| | - Stephanie R Starr
- S.R. Starr is associate professor of pediatrics, Mayo Clinic College of Medicine and Science, and director, Science of Health Care Delivery Education, Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Michael Dekhtyar
- M. Dekhtyar is research associate, Department of Medical Education, University of Illinois College of Medicine at Chicago; ORCID: https://orcid.org/0000-0002-8548-3624
| | - Jed D Gonzalo
- J.D. Gonzalo is professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania; ORCID: https://orcid.org/0000-0003-1253-2963
| | - Stephanie Rennke
- S. Rennke is professor of medicine, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Heather Ridinger
- H. Ridinger is assistant professor of medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna Chang
- A. Chang is professor of medicine, Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| |
Collapse
|
7
|
Griffiths EP, Tong MS, Teherani A, Garg M. First year medical student perceptions of physician advocacy and advocacy as a core competency: A qualitative analysis. MEDICAL TEACHER 2021; 43:1286-1293. [PMID: 34151706 DOI: 10.1080/0142159x.2021.1935829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Medical societies have embraced advocacy as a core professional competency, but little is known about how entering medical students view physician advocacy. This study examined how first year medical students define advocacy, their motivations for and anticipated challenges to advocacy, and whether they believe advocacy should be a core competency. METHOD This study used a qualitative content analysis approach to analyze first year medical student narrative responses about physician advocacy. The analysis included the written responses of 95% of the first-year medical students at the University of California, San Francisco (UCSF) School of Medicine during two academic years. RESULTS Students shared consensus that physicians should advocate on behalf of their individual patients. Students had varying opinions on whether all physicians should engage in societal level advocacy and whether it should be a core competency in medical school. Students find several compelling reasons for physicians to engage in societal advocacy but nevertheless anticipate challenges to physician advocacy. CONCLUSION Given increasing consensus that advocacy is a core competency of physicians, providing medical students the skills to successfully engage in advocacy is increasingly important. Any new mandatory curricula will need to focus on how to engage learners with varied views on advocacy.
Collapse
Affiliation(s)
- Elizabeth P Griffiths
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Michelle S Tong
- School of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Arianne Teherani
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- School of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Megha Garg
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| |
Collapse
|
8
|
Binnendyk J, Pack R, Field E, Watling C. Not wanted on the voyage: highlighting intrinsic CanMEDS gaps in Competence by Design curricula. CANADIAN MEDICAL EDUCATION JOURNAL 2021; 12:39-47. [PMID: 34567304 PMCID: PMC8463229 DOI: 10.36834/cmej.70950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND As governing bodies design new curricula that seek to further incorporate principles of competency-based medical education within time-based models of training, questions have been raised regarding the continued centrality of existing CanMEDS competencies. Although efforts have been made to align these new curricula with CanMEDS, we don't yet know to what extent these competencies are meaningfully integrated. METHODS A content analysis approach was used to systematically evaluate national Canadian curricula for 18 residency-training programs and determine the number of times each enabling CanMEDS competency was represented. RESULTS Clear trends persisted across all programs. Medical Expert and Collaborator competencies were well integrated into curriculum (81% and 86% mapped to assessment) while competencies related to the Leader, Professional, and Health Advocate roles were less frequently mapped to assessment (41%, 36%, and 40%) and were often absent from the new curricula altogether (59%, 64%, and 60%). CONCLUSION Deliberate planning in curriculum development affords the early identification of gaps. These gaps can inform current assessment practice and future curricular development by providing direction for innovation. If we are to ensure that any new curricula meaningfully address all CanMEDS roles, we need to think carefully about how to best teach and assess underrepresented competencies.
Collapse
Affiliation(s)
- Joan Binnendyk
- Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
| | - Rachael Pack
- Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
| | - Emily Field
- Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
| | - Chris Watling
- Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
| |
Collapse
|
9
|
LaDonna KA, Watling CJ, Cristancho SM, Burm S. Exploring patients' and physicians' perspectives about competent health advocacy. MEDICAL EDUCATION 2021; 55:486-495. [PMID: 33152148 DOI: 10.1111/medu.14408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Many residency programmes struggle to demonstrate how they prepare trainees to become competent health advocates. To meaningfully teach and assess it, we first need to understand what 'competent' health advocacy (HA) is and what competently enacting it requires. Attempts at clarifying HA have largely centred around the perspectives of consultant physicians and trainees. Without patients' perspectives, we risk training learners to advocate in ways that may be misaligned with patients' needs and goals. Therefore, the purpose of our research was to generate a multi-perspective understanding about the meaning of competence for the HA role. METHODS We used constructivist grounded theory to explore patients' and physicians' perspectives about competent health advocacy. Data were collected using photo elicitation; patients (n = 10) and physicians (n = 14) took photographs depicting health advocacy that were used to inform semi-structured interviews. Themes were identified using constant comparative analysis. RESULTS Physician participants associated HA with disruption or political activism, suggesting that competence hinged on medical and systems expertise, a conducive learning environment, and personal and professional characteristics including experience, status and political savvy. Patient participants, however, equated physician advocacy with patient centredness, perceiving that competent HAs are empathetic and attentive listeners. In contrast to patients, few physicians identified as advocates, raising questions about their ability to train or to thoughtfully assess learners' abilities. CONCLUSION Few participants perceived HA as a fundamental physician role-at least not as it is currently defined in curricular frameworks. Misperceptions that HA is primarily disruptive may be the root cause of the HA problem; solving it may rely on focusing training on bolstering skills like empathy and listening not typically associated with the HA role. Since there may be no competency where the patient voice is more critical, we need to explore opportunities for patients to facilitate learning for the HA role.
Collapse
Affiliation(s)
- Kori A LaDonna
- Department of Innovation in Medical Education and Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Christopher J Watling
- Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Sayra M Cristancho
- Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Sarah Burm
- Division of Medical Education, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
10
|
Cavanagh A, Vanstone M, Ritz S. Problems of problem-based learning: Towards transformative critical pedagogy in medical education. PERSPECTIVES ON MEDICAL EDUCATION 2019; 8:38-42. [PMID: 30632061 PMCID: PMC6382617 DOI: 10.1007/s40037-018-0489-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Problem-based medical education is based in a biomedical worldview that works to entrench deterministic ways of thinking about socioculturally-influenced health disparities in the minds of medical trainees. This perspective paper considers the utility of Paolo Freire's critical pedagogy as a means of redressing this issue, as it may enable medical learners to perceive and address the social sources of illness that shape their patients' lives. With an eye to advancing health equity, and educating health professionals who are responsive to marginalized and vulnerable communities, this paper considers how a problem-posing medical education could redefine physicians' relationships to knowledge, identity, and to their patients.
Collapse
Affiliation(s)
- Alice Cavanagh
- Health Policy PhD Program, McMaster University, Hamilton, ON, Canada.
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Program for Education Research, Innovation & Theory (MERIT), Hamilton, ON, Canada
| | - Stacey Ritz
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Medical Sciences Division, Northern Ontario School of Medicine, Sudbury, ON, Canada
| |
Collapse
|
11
|
LaDonna KA, Field E, Watling C, Lingard L, Haddara W, Cristancho SM. Navigating complexity in team-based clinical settings. MEDICAL EDUCATION 2018; 52:1125-1137. [PMID: 30345686 DOI: 10.1111/medu.13671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/11/2018] [Accepted: 06/05/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio-relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. METHODS Constructivist grounded theory informed data collection and analysis; during semi-structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. RESULTS Routine care became complex when the prognosis was unknown, when treatment was either non-existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. CONCLUSIONS Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non-physician team members in advocacy training.
Collapse
Affiliation(s)
- Kori A LaDonna
- Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Emily Field
- Department of Women's Studies, Western University, London, Ontario, Canada
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Christopher Watling
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Clinical Neurological Sciences, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lorelei Lingard
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Faculty of Education, Western University, London, Ontario, Canada
| | - Wael Haddara
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sayra M Cristancho
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Faculty of Education, Western University, London, Ontario, Canada
| |
Collapse
|
12
|
Jefferies D, Duff M, Nicholls D. Understanding the experience of women admitted to a psychiatric hospital in Sydney with psychosis or mania following childbirth after World War II (1945-1955). Int J Ment Health Nurs 2018; 27:702-711. [PMID: 28573787 DOI: 10.1111/inm.12357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2017] [Indexed: 11/27/2022]
Abstract
In the present study, we investigated a unique set of historical health-care records of women admitted to a psychiatric hospital in Sydney, Australia with a diagnosis of psychosis or mania after childbirth in the post-World War II (WWII) period, from 1945 to 1955. This research is part of a larger project examining how the descriptions of these women documented in the health-care records from 1885 to 1975 affected their treatment and the outcome of their admission. In the present paper, we report on the findings from an intensive examination of the post WWII documents. Eighteen health-care records from a psychiatric facility (Gladesville Hospital) were identified from admission registers housed in the State Records Office of New South Wales in 2014. Although seven records had been destroyed, 11 were transcribed verbatim. The records contain demographic information; descriptions of the women's signs and symptoms on admission; and information about the women before, during, and after their admission found in letters from relatives or medical staff. A content analysis of admission information showed how the women were described by health-care professionals, but a textual analysis of the records revealed that there were other factors that could have contributed to the women's condition, which might not have been taken into consideration when treatment and care were devised. The present study demonstrates the value of investigating historical health-care records to understand how prevailing attitudes and practices might affect diagnosis and treatment.
Collapse
Affiliation(s)
- Diana Jefferies
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
| | - Margaret Duff
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
| | - Daniel Nicholls
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
| |
Collapse
|
13
|
Douglas A, Mak D, Bulsara C, Macey D, Samarawickrema I. The teaching and learning of health advocacy in an Australian medical school. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2018; 9:26-34. [PMID: 29414796 PMCID: PMC5834824 DOI: 10.5116/ijme.5a4b.6a15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 01/02/2018] [Indexed: 05/06/2023]
Abstract
OBJECTIVES To determine if medical graduates from an Australian university are educated and skilled in health advocacy for their future practice with patients and the wider community. METHODS The authors used an exploratory mixed methodology starting with curriculum mapping of the medical curriculum, followed by key informant interviews with the University of Notre Dame, School of Medicine academics (n = 6) and alumni (n = 5) on teaching/learning and practice of health advocacy. The final stage consisted of a cross-sectional survey on teaching/learning health advocacy among third and fourth (final) year medical students (N = 195). RESULTS The medical curriculum contained no explicit learning objectives on health advocacy. Key informant interviews demonstrated an appreciation of health advocacy and its importance in the medical curriculum but a deficit in explicit and practical 'hands-on' teaching. Survey response rate was 47% (n = 92). A majority of students (76%, n = 70) had heard of health advocacy, with this being more likely among third (92%, n = 33) compared with fourth-year students (67%, n = 37) (Fisher's Exact Test χ2 (2, N = 91) = 7.311, p = 0.02). Students reported having opportunities to observe (76%, n = 70) and practise health advocacy (50%, n = 46) in the curriculum. CONCLUSIONS Students and medical graduates demonstrated sound recognition of the term health advocacy. Deficits identified in the curriculum include lack of explicit learning objectives and "hands-on" learning opportunities in health advocacy.
Collapse
Affiliation(s)
- Arabelle Douglas
- School of Medicine, University of Notre Dame Australia, Australia
| | - Donna Mak
- Population and Preventive Health Domain, School of Medicine, University of Notre Dame Australia, Australia
| | - Caroline Bulsara
- School of Nursing & Midwifery, University of Notre Dame Australia, Australia
| | - David Macey
- School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
| | | |
Collapse
|
14
|
Sharma M, Pinto AD, Kumagai AK. Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:25-30. [PMID: 28445214 DOI: 10.1097/acm.0000000000001689] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Medical schools are increasingly called to include social responsibility in their mandates. As such, they are focusing their attention on the social determinants of health (SDOH) as key drivers in the health of the patients and communities they serve. However, underlying this emphasis on the SDOH is the assumption that teaching medical students about the SDOH will lead future physicians to take action to help achieve health equity. There is little evidence to support this belief. In many ways, the current approach to the SDOH within medical education positions them as "facts to be known" rather than as "conditions to be challenged and changed." Educators talk about poverty but not oppression, race but not racism, sex but not sexism, and homosexuality but not homophobia. The current approach to the SDOH may constrain or even incapacitate the ability of medical education to achieve the very goals it lauds, and in fact perpetuate inequity. In this article, the authors explore how "critical consciousness" and a recentering of the SDOH around justice and inequity can be used to deepen collective understanding of power, privilege, and the inequities embedded in social relationships in order to foster an active commitment to social justice among medical trainees. Rather than calling for minor curricular modifications, the authors argue that major structural and cultural transformations within medical education need to occur to make educational institutions truly socially responsible.
Collapse
Affiliation(s)
- Malika Sharma
- M. Sharma is an infectious diseases physician and Canadian Institutes of Health Research (CIHR) Canadian HIV Trials Network (CTN)/Canadian Foundation for AIDS Research (CANFAR) postdoctoral fellow, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. A.D. Pinto is a family physician and public health specialist, Department of Family and Community Medicine, St. Michael's Hospital, assistant professor, Department of Family and Community Medicine, Faculty of Medicine and Dalla Lana School of Public Health, University of Toronto, clinician-scientist, Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, and director, The Upstream Lab, Toronto, Ontario, Canada. A.K. Kumagai is endocrinologist, professor, and vice chair of education, Department of Medicine, University of Toronto, and F.M. Hill Chair in Humanism Education, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | |
Collapse
|
15
|
Gallagher S, Little M. Doctors on Values and Advocacy: A Qualitative and Evaluative Study. HEALTH CARE ANALYSIS 2016; 25:370-385. [DOI: 10.1007/s10728-016-0322-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
16
|
Rangel JC, Cartmill C, Kuper A, Martimianakis MA, Whitehead CR. Setting the standard: Medical Education's first 50 years. MEDICAL EDUCATION 2016; 50:24-35. [PMID: 26695464 DOI: 10.1111/medu.12765] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/03/2015] [Accepted: 03/20/2015] [Indexed: 05/15/2023]
Abstract
CONTEXT By understanding its history, the medical education community gains insight into why it thinks and acts as it does. This piece provides a Foucauldian archaeological critical discourse analysis (CDA) of the journal Medical Education on the publication of its 50th Volume. This analysis draws upon critical social science perspectives to allow the examination of unstated assumptions that underpin and shape educational tools and practices. METHODS A Foucauldian form of CDA was utilised to examine the journal over its first half-century. This approach emphasises the importance of language, and the ways in which words used affect and are affected by educational practices and priorities. An iterative methodology was used to organise the very large dataset (12,000 articles). A distilled dataset, within which particular focus was placed on the editorial pieces in the journal, was analysed. RESULTS A major finding was the diversity of the journal as a site that has permitted multiple - and sometimes contradictory - discursive trends to emerge. One particularly dominant discursive tension across the time span of the journal is that between a persistent drive for standardisation and a continued questioning of the desirability of standardisation. This tension was traced across three prominent areas of focus in the journal: objectivity and the nature of medical education knowledge; universality and local contexts, and the place of medical education between academia and the community. CONCLUSIONS The journal has provided the medical education community with a place in which to both discuss practical pedagogical concerns and ponder conceptual and social issues affecting the medical education community. This dual nature of the journal brings together educators and researchers; it also gives particular focus to a major and rarely cited tension in medical education between the quest for objective standards and the limitations of standard measures.
Collapse
Affiliation(s)
- Jaime C Rangel
- Department of Sociology, University of Toronto, Toronto, ON, Canada
- Wilson Centre, University Health Network, Toronto, ON, Canada
| | - Carrie Cartmill
- Wilson Centre, University Health Network, Toronto, ON, Canada
| | - Ayelet Kuper
- Wilson Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences, Toronto, ON, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria A Martimianakis
- Wilson Centre, University Health Network, Toronto, ON, Canada
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cynthia R Whitehead
- Wilson Centre, University Health Network, Toronto, ON, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Ambulatory Care Education, Women's College Hospital, Toronto, ON, Canada
| |
Collapse
|
17
|
|
18
|
Hubinette M, Dobson S, Regehr G. Not just 'for' but 'with': health advocacy as a partnership process. MEDICAL EDUCATION 2015; 49:796-804. [PMID: 26152491 DOI: 10.1111/medu.12755] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/23/2015] [Accepted: 03/16/2015] [Indexed: 06/04/2023]
Abstract
CONTEXT Health advocacy is often framed as an activity that physicians do for others. A physician uses her expertise to identify and address the health needs of patients or communities on their behalves. As part of a larger study, we uncovered data to suggest that effective health advocates work not just for but often with others to understand and address their health needs. OBJECTIVES This paper explores and elaborates the important distinction between advocating with and for others. METHODS We interviewed 10 physicians, identified by others as successful health advocates, about their advocacy activities. Informed by constructivist grounded theory, we gathered and evaluated data iteratively, continually revising the interview outline and concurrently refining our evolving themes. Once it had stabilised, the coding scheme was applied to the full set of transcripts. RESULTS Health advocacy was framed by participants as an activity that was more often done with others, than for others. This manifested in two ways: (i) joining other voices: rather than always feeling a need to plan and act alone, our participants often described making efforts to find and join existing initiatives and to work collaboratively, and (ii) amplifying other voices: rather than authoritatively determining needs and enacting solutions on behalf of others, our participants often described making efforts to empower others to find their own voices, thereby fostering autonomy rather than reliance. Participants described factors and mechanisms that enabled them to approach advocacy in this manner. CONCLUSIONS Successful health advocates often enact health advocacy with others, rather than exclusively for them. This partnership-based facilitative approach enables them to better appreciate the needs of those requiring support, and to ask: 'How can I help?' If this approach were more effectively reflected in formal constructions of the process, health advocacy might not only be practised more effectively, but might also be perceived as more achievable by trainees and physicians.
Collapse
Affiliation(s)
- Maria Hubinette
- Department of Family Practice and Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Dobson
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Glenn Regehr
- Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|