An exploration of contextual dimensions impacting goals of care conversations in postgraduate medical education

Development and perception of surgery-specific goals of care discussions in the preoperative setting: A learning pilot

BACKGROUND

Goals of care discussions are infrequently documented in the preoperative period. Furthermore, documentation does not consistently address what matters most to patients, although patient values (PV) are central to person-centered care.

METHODS

A multidisciplinary working group was formed. An electronic note comprised of (1) topics of discussion, (2) PV, and (3) advance care planning (ACP), was created and embedded into existing note templates for Gynecologic Surgical Oncology. Surgeons and advanced practice providers (APPs) were educated to conduct and document these conversations in preoperative clinic for patients undergoing cancer surgery for a pilot period. Data were collected regarding usage of the template. Focus groups with surgeons, APPs, and patients were conducted. Qualitative analysis was performed on transcripts.

RESULTS

During the pilot, 7 surgeon/APP teams utilized the template on a total of 55 notes. Average number of notes completed per surgeon was 7.8 (SD 8.5). Forty-six notes (84%) included topics of discussion, 15 (27%) included PV, 4 (7%) included ACP. Qualitative analysis of focus group transcripts revealed that clinicians and patients perceived the initiative to be useful and important, although implementation barriers were identified.

CONCLUSION

Creating a surgery-specific GOC template is feasible. Iterative revisions are needed to increase utility in clinic workflows.

Conducting Goals of Care Conversations: Lessons From the COVID-19 Pandemic

Objective: Internal medicine (IM) residents discuss a patient's goals of care (GOC) as part of their initial consultation. Residents have described inexperience, general discomfort, limited formal teaching, and prognostic uncertainty as barriers to effective GOC conversations. The early COVID-19 pandemic resulted in rapid changes to the healthcare system on the individual, patient, and systemic level that might exacerbate and/or introduce new barriers to IM residents' GOC conversations. This qualitative study examines how the early COVID-19 pandemic challenged IM residents' ability to have effective GOC conversations. Methods: Using a constructivist grounded theory approach, participants (n=11) completed a semi-structured interview. Data collection and analysis occurred simultaneously using an open coding, constant comparison process. Interviews were completed until no new themes were identified. Results: Residents self-described their GOC conversations in 5 steps: normalization of the conversation, introduction of expected clinical course, discussion of possible care plans, exploration of the patient's values, and occasionally providing a recommendation. Residents described limited structured teaching around GOC conversations and instead relied on observed role-modelling and self-practice to hone their skillset. Residents described an increased sense of urgency to have GOC conversations due to the uncertainty of clinical course and potential for rapid deterioration of patients with COVID-19. Residents identified restrictive visitor policies as a significant barrier that contributed to feelings of dehumanization. Residents felt that these limitations affected their GOC conversations and potentially resulted in discordant care plans which contributed to moral distress. Conclusion: The early COVID-19 pandemic resulted in several barriers that challenged residents' ability to conduct effective GOC conversations. This is on the background of previously reported discomfort and limited formal training in conducting GOC conversations. Based on our findings, we present a conceptual model involving teaching validated GOC frameworks, positive role-modelling, and experiential learning to support GOC conversation education in post-graduate medical education.

Voices of the Future: Junior Physicians' Experiences of Discussing Life-Sustaining Treatments With Hospitalized Patients

OBJECTIVES

Life-sustaining treatments (LST) aim to prolong life without reversing the underlying medical condition. Being associated with a high risk of developing unwanted adverse outcomes, decisions about LST are routinely discussed with patients at hospital admission, particularly when it comes to cardiopulmonary resuscitation. Physicians may encounter many challenges when enforcing shared decision-making in this domain. In this study, we map out how junior physicians in Southern Switzerland refer to their experiences when conducting LST discussions with hospitalized patients and their learning strategies related to this.

METHODS

In this qualitative exploratory study, we conducted semi-directive interviews with junior physicians working at the regional public hospital in Southern Switzerland and analyzed them with an inductive thematic analysis.

RESULTS

Nine physicians participated. We identified 3 themes: emotional burden, learning strategies and practices for conducting discussions. Participants reported feeling unprepared and often distressed when discussing LST with patients. Factors associated with emotional burden were related to the context and to how physicians developed and managed their emotions. Participants signaled having received insufficient education to prepare for discussing LST. They reported learning to discuss LST essentially through trial and error but particularly appreciated the possibility of mentoring and experiential training. Explanations that physicians gave about LST took into account patients' frequent misconceptions. Physicians reported feeling under pressure to ensure that decisions documented were medically indicated and being more at ease when patients decided by themselves to limit treatments. Communication was deemed as an important skill.

CONCLUSIONS

Junior physicians experienced conducting LST discussions as challenging and felt caught between advocating for medically relevant decisions and respecting patients' autonomy. Participants reported a substantive emotional burden and feeling unprepared for this task, essentially because of a lack of adequate training. Interventions aiming to ameliorate junior physicians' competency in discussing LST can positively affect their personal experiences and decisional outcomes.

Internal Medicine Resident Barriers to Advance Care Planning in the Primary Care Continuity Clinic

Background: While primary care providers regularly engage in Advance Care Planning (ACP) conversations, it is not well known what challenges resident physicians face to achieving this core competency. Objectives: We aimed to assess resident perceptions of barriers and potential interventions to outpatient ACP. Methods: We distributed an electronic survey to Internal Medicine and Medicine-Psychiatry residents at our institution in 2022. Questions addressed outpatient ACP barriers and potential interventions in several domains: structural issues, personal knowledge, and communication skills. We reported results using descriptive statistics and Wilcoxon rank-sum tests, comparing responses by residency year (interns vs upperyears). Likert-scale responses were dichotomized to a "not at all or slightly" vs "moderate or extreme" barrier or helpful intervention. Results: Of 149 residents, 71 completed the survey (48%). Highest scoring barriers were structural, including 1) lack of clinic time (99%), 2) need to prioritize other medical problems (94%), and 3) lack of patient continuity (62%). Highest scoring interventions included the ability to schedule dedicated ACP visits with themselves (96%) or another clinician (82%). Interns were statistically significantly less confident in their ability to conduct ACP, and more likely to report lack of knowledge (i.e., not understanding ACP, patient prognosis, or how to complete paperwork, P < .05). Conclusions: Residents report significant structural barriers to outpatient ACP, including limitations in time, continuity, and competing medical priorities, that may warrant greater program attention to interventions such as clinic schedules and work-flow. Additional trainings may be most beneficial if targeted to the beginning of intern year.

A Scoping Review of Gaps Identified by Primary Care Providers in Caring for Patients with Chronic Noncancer Pain

Introduction/Aim

Primary care providers (PCPs), who provide the bulk of care for patients with chronic noncancer pain (CNCP), often report knowledge gaps, limited resources, and difficult patient encounters while managing chronic pain. This scoping review seeks to evaluate gaps identified by PCPs in providing care to patients with chronic pain.

Methods

The Arksey and O'Malley framework was used for this scoping review. A broad literature search was conducted for relevant articles on gaps in knowledge and skills of PCPs and in their health care environment for managing chronic pain, with multiple search term derivatives for concepts of interest. Articles from the initial search were screened for relevance, yielding 31 studies. Inductive and deductive thematic analysis was adopted.

Results

The studies included in this review reflected a variety of study designs, settings, and methods. However, consistent themes emerged with respect to gaps in knowledge and skills for assessment, diagnosis, treatment, and interprofessional roles in chronic pain, as well as broader systemic issues including attitudes toward CNCP. A general lack of confidence in tapering high dose or ineffective opioid regimes, professional isolation, challenges in managing patients with CNCP with complex needs, and limited access to pain specialists were reported by PCPs.

Discussion/Conclusions

This scoping review revealed common elements across the selected studies that will be useful in guiding creation of targeted supports for PCPs to manage CNCP. This review also yielded insights for pain clinicians at tertiary centers for supporting their PCP colleagues as well as systemic reforms required to support patients with CNCP.

Goals of care conversation education program: An intervention to help health care professionals break bad news to patients with advanced illness

The purpose of the study was to measure the effectiveness of communication skills intervention results for healthcare professionals. A multi-site pretest-posttest survey assessing the efficacy of a Goals of Care conversation education program. The program aimed to educate healthcare professionals concerning having Goals of Care conversations with patients and families. This research was implemented in a large healthcare organization in the Northeastern United States. This study found significant differences between pretests and posttests across professions, palliative care specialty, degree types, and years of experience in the participant's self-reported ability and comfort levels in having conversations about Goals of Care with patients and families. Providing education on Goals of Care was effective in improving the knowledge and comfort of health care professionals with conducting advanced illness conversations.

"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.

Complexities of Continuing Professional Development in Context: Physician Engagement in Clinical Coaching

INTRODUCTION

Effective continuing professional development (CPD) is critical for safe and effective health care. Recent shifts have called for a move away from didactic CPD, which often fails to affect practice, toward workplace learning such as clinical coaching. Unfortunately, coaching programs are complex, and adoption does not guarantee effectiveness. To resolve this problem, thus ensuring resources are well spent, there is a critical need to understand what physicians try to achieve and how they engage. Therefore, we examined the types of change physicians pursue through clinical coaching and the impact of context on their desired changes.

METHODS

In the context of two clinical coaching programs for rural physicians, we applied a generic qualitative approach. Coachees (N = 15) participated in semistructured interviews. Analysis involved iterative cycles of initial, focused, and theoretical coding.

RESULTS

Coachees articulated desired practice changes along a spectrum, ranging from honing their current practice to making larger changes that involved new skills outside their current practice; changes also ranged from those focused on individual physicians to those focused on the practice system. Desired changes were affected by factors in the learning/practice environment, including those related to the individual coachee, coach, and learning/practice context.

DISCUSSION

These results suggest that the current focus on acquiring new knowledge through CPD may miss important learning that involves subtle shifts in practice as well as learning that focusses on systems change. Moreover, an appreciation of the contextual nature of CPD can ensure that contextual affordances are leveraged and barriers are acknowledged.

Impact of Dying Neonates on Doctors' and Nurses' Personhood: A Systematic Scoping Review

CONTEXT

Caring for dying neonates is distressing for healthcare professionals (HCP)s. Yet, the extent of these effects is poorly understood, compromising support of HCPs. To better understand and support HCPs, a systematic scoping review (SSR) of prevailing data is proposed.

OBJECTIVES

In mapping prevailing data on the impact of caring for dying neonates on HCPs, an SSR proffers new insights on changes to their beliefs, values, coping, actions, relationships and self-concepts of personhood.

METHODS

Krishna's Systematic Evidenced Based Approach (SEBA) supports a robust, reproducible review whilst its constructivist approach and relativist lens effectively contends with diverse data sources, facilitating a holistic study.

RESULTS

A total of 9826 abstracts were reviewed and 69 articles were included. Thematic and content analysis were used simultanously. The four categories drawn from the Ring Theory of Personhood (RToP) complements the four themes identified: Emotional and Physical Difficulties, Coping Mechanisms, Conflict and Recommendations.

CONCLUSION

In highlighting significant longitudinal effects upon all aspects of their lives, this SSR in SEBA reveals a critical need for timely, appropriate and personalized support. We recommend adapting the RToP as an assessment tool to identify and evaluate the needs of these HCPs. It may also be used to structure a holistic support mechanism. Future studies are required to validate its use and appraise other aspects of support available for HCPs.

A systematic scoping review and thematic analysis of interprofessional mentoring in medicine from 2000 to 2019

Interprofessional mentoring in palliative care sees different members of the interprofessional team providing holistic, personalised andlongitudinal mentoring support, skills training and knowledge transfer as they mentor trainees at different points along their mentoring journeys. However, gaps in practice and their risk of potential mentoring malpractice even as interprofessional mentoring use continues to grow in palliative medicine underlines the need for careful scrutiny of its characteristics and constituents in order to enhance the design, evaluation and oversight of interprofessional mentoring programmes. Hence, a systematic scoping review on prevailing accounts of interprofessional mentoring in medicine is conducted to address this gap. Using Arksey and O'Malley's (2005) methodological framework for conducting scoping reviews and identical search strategies, 6 reviewers performed independent literature reviews of accounts of interprofessional mentoring published in 10 databases. Braun and Clarke's (2006) thematic analysis approach was adopted to evaluate across different mentoring settings. A total of 11111 abstracts were identified from 10 databases, 103 full-text articles reviewed and 14 full-text articles were thematically analysed to reveal 4 themes: characterizing, implementing, evaluating and obstacles to interprofessional mentoring. Interprofessional mentoring is founded upon a respectful and collaborative mentoring relationship that thrives despite inevitable differences in individual values, ethical perspectives at different career stages within diverse working environments. This warrants effective mentor-mentee trainings, alignment of expectations, roles and responsibilities, goals and timelines, and effective oversight of the programmes. Drawing upon the data provided, an interprofessional mentoring framework is forwarded to guide the design, evaluation and oversight of the programmes.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Combined novice, near-peer, e-mentoring palliative medicine program: A mixed method study in Singapore

INTRODUCTION

An acute shortage of senior mentors saw the Palliative Medicine Initiative (PMI) combine its novice mentoring program with electronic and peer mentoring to overcome insufficient mentoring support of medical students and junior doctors by senior clinicians. A three-phased evaluation was carried out to evaluate mentees' experiences within the new CNEP mentoring program.

METHODS

Phase 1 saw use of a Delphi process to create a content-valid questionnaire from data drawn from 9 systematic reviews of key aspects of novice mentoring. In Phase 2 Cognitive Interviews were used to evaluate the tool. The tool was then piloted amongst mentees in the CNEP program. Phase 3 compared mentee's experiences in the CNEP program with those from the PMI's novice mentoring program.

RESULTS

Thematic analysis of open-ended responses revealed three themes-the CNEP mentoring process, its benefits and challenges that expound on the descriptive statistical analysis of specific close-ended and Likert scale responses of the survey. The results show mentee experiences in the PMI's novice mentoring program and the CNEP program to be similar and that the addition of near peer and e-mentoring processes enhance communications and support of mentees.

CONCLUSION

CNEP mentoring is an evolved form of novice mentoring built on a consistent mentoring approach supported by an effective host organization. The host organization marshals assessment, support and oversight of the program and allows flexibility within the approach to meet the particular needs of mentees, mentors and senior mentors. Whilst near-peer mentors and e-mentoring can make up for the lack of senior mentor availability, their effectiveness hinges upon a common mentoring approach. To better support the CNEP program deeper understanding of the mentoring dynamics, policing and mentor and mentee training processes are required. The CNEP mentoring tool too needs to be validated.

How to ensure basic competencies in end of life care - a mixed methods study with post-graduate trainees in primary care in Germany

Background

Providing end of life care (EoLC) is an important aspect of primary care, which reduces the risk of hospital admission for most patients. However, general practitioners (GPs) seem to have low confidence in their ability to provide EoLC. Little is known about an adequate volume and kind of training in EoLC among GP trainees.

Methods

We performed a before-after comparison in all post-graduate GP trainees who were registered in the vocational training program (KWBW VerbundweiterbildungPLUS). They were offered participation within a two-day seminar focussing on palliative care in 2017. Those who attended the seminar (intervention group I) completed a paper-based questionnaire directly before the intervention (T₁) and 6 months after (T₂). None-attendees (group C) were also asked to fill out the questionnaire once. The questionnaire covered previous experiences in palliative care, self-assessment of competencies in EoLC in the organisation of patient care as well as in control of symptoms, attitudes towards death and caring for dying patients and questions about GPs’ role in EoLC.

Results

In total, 294 GP trainees (I: n = 219; C: n = 75) participated in the study. Of those, more than 90% had previously gained experience in EoLC mainly during vocational training in the hospital rotation. Around a third had previously gained competencies in EoLC in medical school. Between groups I (T₁) and C no significant differences were observed in socio-demographic characteristics, pre-existing experience or overall expertise. At T_2, 75% of participants of group I declared they have extended their competencies in EoLC after the intervention and 70% classified the intervention as helpful or very helpful. Overall, they rated their competencies significantly higher than at T₁ (p < 0.01). In detail, competencies in organisation of EoLC and competencies in handling of symptoms significantly improved (p < 0.01). Due to the intervention, 66% could reflect their attitudes towards dying, death and grief and 18% changed their attitudes. Group I highlighted palliative care as one of GPs tasks (Likert 4.47/5, SD 0.75).

Conclusions

The intervention fostered personal competencies, understanding and self-confidence in EoLC among GP trainees. This is crucial for the aim to broadly provide EoLC.

Enhancing mentoring experiences through e-mentoring: a systematic scoping review of e-mentoring programs between 2000 and 2017

Mentoring is suffering from a shortage of trained mentors which compromise the efficacy of novice mentoring or mentoring between a senior clinician and a junior clinician. E-mentoring is proposed as a means of supplementing this dominant form of mentoring in medicine by providing accessible, timely and longitudinal support for mentees. However, with little is known about e-mentoring nor its role in a blended mentoring approach, a systematic scoping review is proposed to evaluate these gaps in understanding in order to better understand e-mentoring and assess the viability of employing e-mentoring practice to support novice mentoring. Using Arksey and O'Malley's (Int J Soc Res Methodol 8(1):19-32, 2005) approach, 5 reviewers carried out independent literature reviews of e-mentoring as an adjuvant to novice mentoring in PubMed, Embase, PsycINFO, ERIC, Cochrane Database of Systematic Reviews, Google Scholar, Scopus, GreyLit, OpenGrey, and Web of Science databases. Braun and Clarke's (Qual Res Psychol 3(2):77-101, 2006) thematic analysis approach was used to thematically analyse accounts of e-mentoring across different settings. 6557 abstracts were identified, 109 full text articles were reviewed, and 18 articles were included and thematically analysed. The themes identified include definitions, role, stages, processes, platforms, evaluation, and relationships in e-mentoring. The themes identified provide a clinically relevant definition of e-mentoring, and in highlighting the similarities in the phases of novice and e-mentoring reaffirms the validity of a blended approach as a means of addressing shortfalls in mentoring in medicine.

Training clinical ethics committee members between 1992 and 2017: systematic scoping review

INTRODUCTION

Clinical ethics committees (CECs) support and enhance communication and complex decision making, educate healthcare professionals and the public on ethical matters and maintain standards of care. However, a consistent approach to training members of CECs is lacking. A systematic scoping review was conducted to evaluate prevailing CEC training curricula to guide the design of an evidence-based approach.

METHODS

Arksey and O'Malley's methodological framework for conducting scoping reviews was used to evaluate prevailing accounts of CEC training published in six databases. Braun and Clarke's thematic analysis approach was adopted to thematically analyse data across different healthcare and educational settings.

RESULTS

7370 abstracts were identified, 92 full-text articles were reviewed and 55 articles were thematically analysed to reveal four themes: the design, pedagogy, content and assessment of CEC curricula.

CONCLUSION

Few curricula employ consistent approaches to training. Many programmes fail to provide CEC trainees with sufficient knowledge, skills and experience to meet required competencies. Most programmes do not inculcate prevailing sociocultural, research, clinical and educational considerations into training processes nor provide longitudinal support for CEC trainees. Most CEC training programmes are not supported by host institutions threatening the sustainability of the programme and compromising effective assessment and longitudinal support of CEC trainees. While further reviews are required, this review underlines the need for host organisations to support and oversee a socioculturally appropriate ethically sensitive, clinically relevant longitudinal training, assessment and support process for CEC trainees if CECs are to meet their roles effectively.

Medical students' experiences with goals of care discussions and their impact on professional identity formation

CONTEXT

Goals of care (GoC) discussions occur amongst patients, family members and clinicians in order to establish plans of care and are invaluable aspects of end-of-life care. In previous research, medical learners have reported insufficient training and emotional distress about end-of-life decision making, but most studies have focused on postgraduate trainees and have been quantitative or have evaluated specific educational interventions. None have qualitatively explored medical students' experiences with GoC discussions, their perceptions of associated hidden curricula, and the impacts of these on professional identity formation (PIF), the individualised developmental processes by which laypersons evolve to think, act and feel like, and ultimately become, medical professionals.

METHODS

Using purposive sampling at one Canadian medical school, individual semi-structured interviews were conducted with 18 medical students to explore their experiences with GoC discussions during their core internal medicine clerkship. Interviews were audiorecorded, transcribed and anonymised. Concurrently with data collection, transcripts were analysed iteratively and inductively using interpretative phenomenological analysis, a qualitative research approach that allows the rich exploration of subjective experiences.

RESULTS

Participants reported minimal support and supervision in conducting GoC discussions, which were experienced as ethically challenging, emotionally powerful encounters exemplifying tensions between formal and hidden curricula. Role modelling and institutional culture were key mechanisms through which hidden curricula were transmitted, subverting formal curricula in doing so and contributing to participants' emotional distress. Participants' coping responses were generally negative and included symptoms of burnout, the pursuit of standardisation, rationalisation, compartmentalisation and the adaptation of previously held, more idealised professional identities.

CONCLUSIONS

GoC discussions in this study were often led by inexperienced medical students and impacted negatively on their PIF. Through complex emotional processes, they struggled to reconcile earlier concepts of physician identities with newly developing ones and often reluctantly adopted suboptimal professional behaviours and attitudes. Improved education about GoC discussions is necessary for patient care and may represent concrete and specific opportunities to influence students' PIF positively.

Educational roles as a continuum of mentoring's role in medicine - a systematic review and thematic analysis of educational studies from 2000 to 2018

BACKGROUND

Recent studies have gone to great lengths to differentiate mentoring from teaching, tutoring, role modelling, coaching and supervision in efforts to better understand mentoring processes. This review seeks to evaluate the notion that teaching, tutoring, role modelling, coaching and supervision may in fact all be part of the mentoring process. To evaluate this theory, this review scrutinizes current literature on teaching, tutoring, role modelling, coaching and supervision to evaluate their commonalities with prevailing concepts of novice mentoring.

METHODS

A three staged approach is adopted to evaluate this premise. Stage one involves four systematic reviews on one-to-one learning interactions in teaching, tutoring, role modelling, coaching and supervision within Internal Medicine, published between 1st January 2000 and 31st December 2018. Braun and Clarke's (2006) approach to thematic analysis was used to identify key elements within these approaches and facilitate comparisons between them. Stage two provides an updated view of one-to-one mentoring between a senior physician and a medical student or junior doctor to contextualise the discussion. Stage three infuses mentoring into the findings delineated in stage one.

RESULTS

Seventeen thousand four hundred ninety-nine citations were reviewed, 235 full-text articles were reviewed, and 104 articles were thematically analysed. Four themes were identified - characteristics, processes, nature of relationship, and problems faced in each of the four educational roles.

CONCLUSIONS

Role modelling, teaching and tutoring, coaching and supervision lie within a mentoring spectrum of increasingly structured interactions, assisted by assessments, feedback and personalised support that culminate with a mentoring approach. Still requiring validation, these findings necessitate a reconceptualization of mentoring and changes to mentor training programs and how mentoring is assessed and supported.

Mentoring stages: A study of undergraduate mentoring in palliative medicine in Singapore

BACKGROUND

Mentoring nurtures a mentee's personal and professional development. Yet conflation of mentoring approaches and a failure to contend with mentoring's nature makes it difficult to study mentoring processes and relationships. This study aims to understand of mentee experiences in the Palliative Medicine Initiative (PMI). The PMI uses a consistent mentoring approach amongst a homogeneous mentee population offers a unique opportunity to circumnavigate conflation of practices and the limitations posed by mentoring's nature. The data will advance understanding of mentoring processes.

METHODS

Sixteen mentees discussed their PMI experiences in individual face-to-face audio-recorded interviews. The two themes identified from thematic analysis of interview transcripts were the stages of mentoring and communication.

RESULTS

The 6 stages of mentoring are the 'pre-mentoring stage', 'initial research meetings', 'data gathering', 'review of initial findings, 'manuscript preparation" and 'reflections'. These subthemes sketch the progression of mentees from being dependent on the mentor for support and guidance, to an independent learner with capacity and willingness to mentor others. Each subtheme is described as stages in the mentoring process (mentoring stages) given their association with a specific phase of the research process. Mentoring processes also pivot on effective communication which are influenced by the mentor's characteristics and the nature of mentoring interactions.

CONCLUSION

Mentoring relationships evolve in stages to ensure particular competencies are met before mentees progress to the next part of their mentoring process. Progress is dependent upon effective communication and support from the mentor and appropriate and timely adaptations to the mentoring approach to meet the mentee's needs and goals. Adaptations to the mentoring structure are informed by effective and holistic evaluation of the mentoring process and the mentor's and mentee's abilities, goals and situations. These findings underline the need to review and redesign the way assessments of the mentoring process are constructed and how mentoring programs are structured.

Common Items on a Bucket List

BACKGROUND

To provide preference-sensitive care, we propose that clinicians might routinely inquire about their patients' bucket-lists and discuss the impact (if any) of their medical treatments on their life goals.

METHODS

This cross-sectional, mixed methods online study explores the concept of the bucket list and seeks to identify common bucket list themes. Data were collected in 2015-2016 through an online survey, which was completed by a total of 3056 participants across the United States. Forty participants who had a bucket list were identified randomly and used as the development cohort: their responses were analyzed qualitatively using grounded theory methods to identify the six key bucket list themes. The responses of the remaining 3016 participants were used for the validation study. The codes identified from the development cohort were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 3016 validation cohort transcripts were coded for presence or absence of each of the six bucket list themes.

RESULTS

Around 91.2% participants had a bucket list. Age and spirituality influence the patient's bucket-list. Participants who reported that faith/religion/spirituality was important to them were most likely (95%) to have a bucket list compared with those who reported it to be unimportant (68.2%), χ² = 37.67. Six primary themes identified were the desire to travel (78.5%), desire to accomplish a personal goal (78.3%), desire to achieve specific life milestones (51%), desire to spend quality time with friends and family (16.7%), desire to achieve financial stability (24.3%), and desire to do a daring activity (15%).

CONCLUSIONS

The bucket list is a simple framework that can be used to engage patients about their healthcare decision making. Knowing a patient's bucket list can aid clinicians in relating each treatment option to its potential impact (if any) on the patient's life and life goals to promote informed decision making.

Twelve tips for just in time teaching of communication skills for difficult conversations in the clinical setting

The ability to communicate well with patients and other members of the healthcare team is a vital skill for physicians to have, but one that is often not emphasized in medical education. Learners of all levels can obtain and develop good communication skills regardless of their natural ability in this area, and the clinical setting represents an underutilized resource to accomplish this task. With this in mind, we have reviewed the growing body of literature on the subject and organized our findings into twelve tips to help educators capitalize on these missed opportunities. While our emphasis is helping learners with difficult discussions, these tips can be easily adapted to any other clinical encounter requiring clear communication. Teaching effective communication skills in the clinical setting requires some extra time, but the steps outlined should not take more than a few minutes to complete. Taking the time to develop these skills in our learners will make a significant difference not only their lives but also their patients and their families.