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Gisby A, Ross C, Francis-Smythe J, Anderson K. The ‘Rich Pictures’ Method: Its Use and Value, and the Implications for HRD Research and Practice. Human Resource Development Review 2023. [DOI: 10.1177/15344843221148044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Embracing new and innovative qualitative methods has helped researchers in a number of fields to access aspects of the lived experience that traditional methods cannot easily reach. This paper explores the use and value of one such method – ‘rich pictures’: a technique whose origins lie in ‘soft systems’ engineering but which has been successfully applied in a broader range of contexts in recent years including health, medicine and education. Despite its use in these disciplines, however, recent studies suggest that HRD research continues to rely on established methods and that uptake of visual methods – and ‘rich pictures’ in particular – is virtually non-existent. The aim of this paper therefore is to shed light on this underused method and encourage HRD researchers to recognize its potential for studying human development.
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Affiliation(s)
- Alison Gisby
- School of Psychology & Counselling, The Open University, Milton Keynes, UK
| | - Catharine Ross
- Worcester Business School, University of Worcester, Worcester, UK
| | | | - Kazia Anderson
- School of Psychology, University of Leicester, Leicester, UK
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Machado MB, Ribeiro DL, de Carvalho Filho MA. Social justice in medical education: inclusion is not enough-it's just the first step. Perspect Med Educ 2022; 11:187-195. [PMID: 35604538 PMCID: PMC9391538 DOI: 10.1007/s40037-022-00715-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/14/2022] [Accepted: 04/26/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Medical schools worldwide are creating inclusion policies to increase the admission of students from vulnerable social groups. This study explores how medical students from vulnerable social groups experience belongingness as they join the medical community. METHODS This qualitative study applied thematic analysis to 10 interviews with medical students admitted to one medical school through an affirmative policy. The interviews followed the drawing of a rich picture, in which the students represented a challenging situation experienced in their training, considering their socio-economic and racial background. The analysis was guided by the modes of belonging (engagement, imagination, and alignment) described by the Communities of Practice framework. RESULTS Participants struggled to imagine themselves as future doctors because they lack identification with the medical environment, suffer from low self-esteem, aside from experiencing racial and social discrimination. Participants also find it troublesome to engage in social and professional activities because of financial disadvantages and insufficient support from the university. However, participants strongly align with the values of the public health system and show deep empathy for the patients. DISCUSSION Including students with different socio-economic and racial backgrounds offers an opportunity to reform the medical culture. Medical educators need to devise strategies to support students' socialization through activities that increase their self-esteem and make explicit the contributions they bring to the medical community.
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Affiliation(s)
| | - Diego Lima Ribeiro
- Interdisciplinary Center of Bioethics, Faculty of Medical Sciences, University of Campinas (UNICAMP), São Paulo, Brazil
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Bood ZM, van Liemt F, Sprangers MAG, Kobes A, Weeseman Y, Scherer-Rath M, Tromp JM, van Laarhoven HWM, Helmich E. This is what life with cancer looks like: exploring experiences of adolescent and young adults with cancer using two visual approaches. Support Care Cancer 2022; 30:3353-3361. [PMID: 34988705 PMCID: PMC8730754 DOI: 10.1007/s00520-021-06775-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/18/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Talking about illness experience can be challenging for adolescents and young adults (AYAs) with cancer. Visual tools, in addition to spoken language, might make this easier, such as rich pictures and photovoice. We aimed to obtain a comprehensive view of the cancer experience of AYAs by using rich pictures and photovoice. METHODS AYAs (18-35 years old) who had any type of cancer, or were in remission from cancer, were eligible. AYAs drew rich pictures about their experience of living with cancer and explained these during subsequent interviews. Some of the AYAs also participated in photovoice and spent two days with a photographer to make photos about their illness experience. Rich pictures and photos were first analyzed separately, using open coding, after which the identified themes were compared. RESULTS Twelve AYAs made rich pictures (RPs), of whom seven also participated in photovoice. The two most predominant themes emerging from the data were struggles related to the future and defining one's identity. The AYAs expressed concerns for the future related to relationships, education, and employment. Relating to defining one's identity, many AYAs expressed that the cancer had a negative impact on their body- and self-image. The main themes were visible in the RPs as well as in the photovoice; however, subtle differences in sub-themes were found. CONCLUSIONS We found that cancer has an effect on many aspects of AYAs' lives. Further research on how the identified themes play a role in the lives of AYAs with cancer is needed.
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Affiliation(s)
- Zarah M Bood
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | | | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Annita Kobes
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Yvonne Weeseman
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Michael Scherer-Rath
- Faculty of Philosophy, Theology, and Religious Studies, Radboud University-Nijmegen, Nijmegen, The Netherlands
| | - Jacqueline M Tromp
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Esther Helmich
- Amsta Healthcare Organisation, Amsterdam, the Netherlands
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van Duin TS, de Carvalho Filho MA, Pype PF, Borgmann S, Olovsson MH, Jaarsma ADC, Versluis MAC. Junior doctors' experiences with interprofessional collaboration: Wandering the landscape. Med Educ 2022; 56:418-431. [PMID: 34890487 PMCID: PMC9305225 DOI: 10.1111/medu.14711] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 05/17/2023]
Abstract
CONTEXT The transition from medical student to junior doctor is challenging. Junior doctors need to become part of the physician community of practice (CoP), while dealing with new responsibilities, tasks and expectations. At the same time, they need to learn how to navigate the frontiers and intersections with the other communities of practice that form the Landscape of Practice (LoP). This study aims to understand how junior doctors experience interprofessional collaboration (IPC) and what elements shape these experiences considering their transition to clinical practice. METHODS In this multicentre qualitative study, 13 junior doctors individually drew two rich pictures of IPC experiences, one positive and one negative. A rich picture is a visual representation, a drawing of a particular situation intended to capture the complex and non-verbal elements of an experience. We used semi-structured interviews to deepen the understanding of junior doctors' depicted IPC experiences. We analysed both visual materials and interview transcripts iteratively, for which we adopted an inductive constructivist thematic analysis. RESULTS While transitioning into a doctor, junior doctors become foremost members of the physician CoP and shape their professional identity based on perceived values in their physician community. Interprofessional learning occurs implicitly, without input from the interprofessional team. As a result, junior doctors struggle to bridge the gap between themselves and the interprofessional team, preventing IPC learning from developing into an integrative process. This professional isolation leaves junior doctors wandering the landscape of practice without understanding roles, attitudes and expectations of others. CONCLUSIONS Learning IPC needs to become a collective endeavour and an explicit learning goal, based on multisource feedback to take advantage of the expertise already present in the LoP. Furthermore, junior doctors need a safe environment to embrace and reflect on the emotions aroused by interprofessional interactions, under the guidance of experienced facilitators.
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Affiliation(s)
- Titia S. van Duin
- Center for Education Development and Research in Health Professions (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Centre GroningenUniversity of GroningenGroningenNetherlands
| | - Marco A. de Carvalho Filho
- Center for Education Development and Research in Health Professions (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Centre GroningenUniversity of GroningenGroningenNetherlands
- Faculty of Veterinary MedicineUtrecht UniversityUtrechtNetherlands
| | - Peter F. Pype
- Department of Family Medicine and Primary Health CareGhent UniversityGhentBelgium
| | - Susanne Borgmann
- Student Deanery of the Faculty of MedicineUniversity Medical Center GöttingenGöttingenGermany
| | - Matts H. Olovsson
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - A. Debbie C. Jaarsma
- Center for Education Development and Research in Health Professions (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Centre GroningenUniversity of GroningenGroningenNetherlands
- Faculty of Veterinary MedicineUtrecht UniversityUtrechtNetherlands
| | - Marco A. C. Versluis
- Department of Obstetrics and GynaecologyUniversity Medical Centre GroningenGroningenNetherlands
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Nimmon L, Atherley A. Qualitative ego networks in health professions education: Capturing the self in relation to others. Med Educ 2022; 56:71-81. [PMID: 34490649 DOI: 10.1111/medu.14663] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Our very sense of self emerges through interactions with others. As part of this State of the Science series on Self, Society, and Situation, we introduce a qualitative ego network research approach. This research approach offers insights into the self's (the ego's) interpretation of and relation to named others in the social network in question. PURPOSE Visual mapping of participants' social networks is gaining traction, yet this research approach has received no focused attention in the health professions education (HPE) literature. A qualitative ego network approach is a compelling research approach because it uniquely maps participants' perceptions of the complex social world they are embedded in. Although many methodologies can explore participants' social world, ego networks can enhance expression of tacit knowledge of one's social environment and encourage reflection. This approach, combined with other qualitative data, can also reveal hidden relational data that the researcher may not observe or consider. To demonstrate its value as a visual methodology, we will showcase two examples of qualitative ego network studies. We then balance the paper with some critical reflections of this research approach. CONCLUSIONS A qualitative ego network approach holds potential for deepening understanding of the self in relation to society and situation in future HPE research. We look forward to intentional, impactful and invigorated research using a qualitative ego network approach as we tackle unknowns about how self and society in specific HPE situations interact.
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Affiliation(s)
- Laura Nimmon
- Centre for Health Education Scholarship, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Anique Atherley
- Academy of Teaching and Learning, Ross University School of Medicine, Barbados Campus, Bridgetown, Barbados
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Velthuis F, Dekker H, Coppoolse R, Helmich E, Jaarsma D. Educators' experiences with governance in curriculum change processes; a qualitative study using rich pictures. Adv Health Sci Educ Theory Pract 2021; 26:1027-1043. [PMID: 33646467 PMCID: PMC8338851 DOI: 10.1007/s10459-021-10034-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/29/2021] [Indexed: 05/25/2023]
Abstract
In the midst of continuous health professions curriculum reforms, critical questions arise about the extent to which conceptual ideas are actually put into practice. Curricula are often not implemented as intended. An under-explored aspect that might play a role is governance. In light of major curriculum changes, we explored educators' perspectives of the role of governance in the process of translating curriculum goals and concepts into institutionalized curriculum change at micro-level (teacher-student). In three Dutch medical schools, 19 educators with a dual role (teacher and coordinator) were interviewed between March and May 2018, using the rich pictures method. We employed qualitative content analysis with inductive coding. Data collection occurred concurrently with data analysis. Different governance processes were mentioned, each with its own effects on the curriculum and organizational responses. In Institute 1, participants described an unclear governance structure, resulting in implementation chaos in which an abstract educational concept could not be fully realized. In Institute 2, participants described a top-down and strict governance structure contributing to relatively successful implementation of the educational concept. However it also led to demotivation of educators, who started rebelling to recover their perceived loss of freedom. In Institute 3, participants described a relatively fragmentized process granting a lot of freedom, which contributed to contentment and motivation but did not fully produce the intended changes. Our paper empirically illustrates the importance of governance in curriculum change. To advance curriculum change processes and improve their desired outcomes it seems important to define and explicate both hard and soft governance processes.
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Affiliation(s)
- Floor Velthuis
- Center for Education Development and Research in Health Professions (CEDAR), University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
| | - Hanke Dekker
- Center for Education Development and Research in Health Professions (CEDAR), University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Remco Coppoolse
- Research Group Normative Professionalization, University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - Esther Helmich
- Center for Education Development and Research in Health Professions (CEDAR), University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Debbie Jaarsma
- Center for Education Development and Research in Health Professions (CEDAR), University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
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Bood ZM, Scherer-Rath M, Sprangers MAG, Timmermans L, van Wolde E, Cristancho SM, Heyning F, Russel S, van Laarhoven HWM, Helmich E. Repeated use of rich pictures to explore changes in subjective experiences over time of patients with advanced cancer. Cancer Rep (Hoboken) 2021; 5:e1428. [PMID: 34313027 PMCID: PMC8789615 DOI: 10.1002/cnr2.1428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/09/2021] [Accepted: 05/05/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The combination of verbal and visual tools may help unravel the experiences of advanced cancer patients. However, most previous studies have focused on a specific symptom, at only one moment in time. We recently found that a specific visual tool, originating from systems thinking, that is, rich pictures (RPs), could provide a more comprehensive view of the experiences of patients with advanced cancer. AIMS To examine whether the repeated use of RPs can make changes in subjective experiences of patients living with advanced cancer visible over time. METHODS AND RESULTS We performed a prospective study with a generic qualitative approach that was mostly informed by the process of grounded theory. We invited patients to make an RP twice, at the start of the study, and again after 2 months. Both RP drawing sessions were directly followed by a semi-structured interview. Patients with all types of solid tumors, above the age of 18, and with a diagnosis of advanced, incurable cancer, were eligible. Eighteen patients participated and 15 patients were able to draw an RP twice. In eight RP-sets, considerable differences between the first and second RP were noticeable. Two patterns were distinguished: (1) a change (decline or improvement) in physical health (five patients), and/or (2) a change in the way patients related to cancer (three patients). CONCLUSION RPs are a valuable qualitative research method that can be used to explore the experiences of patients with advanced cancer, not only at a single point in time but also over time.
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Affiliation(s)
- Zarah M Bood
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael Scherer-Rath
- Faculty of Philosophy, Theology, and Religious Studies, Radboud University-Nijmegen, Nijmegen, The Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Liesbeth Timmermans
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ellen van Wolde
- Faculty of Philosophy, Theology, and Religious Studies, Radboud University-Nijmegen, Nijmegen, The Netherlands
| | - Sayra M Cristancho
- Centre for Education Research & Innovation and Department of Surgery, Health Sciences Addition, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fenna Heyning
- Association of Topclinical hospitals STZ, Utrecht, The Netherlands
| | | | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Esther Helmich
- Center for Education Development and Research in Health Professions, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Ribeiro DL, Costa M, Helmich E, Jaarsma D, de Carvalho‐Filho MA. 'I found myself a despicable being!': Medical students face disturbing moral dilemmas. Med Educ 2021; 55:857-871. [PMID: 33386638 PMCID: PMC8248051 DOI: 10.1111/medu.14447] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/05/2020] [Accepted: 12/26/2020] [Indexed: 06/12/2023]
Abstract
CONTEXT The psychological realm of medical students' moral experiences is explored tangentially in medical education literature, often in the context of ethics or professionalism education. This study deepens our understanding by (a) investigating the nature of moral dilemmas experienced at the onset of clinical practice, (b) exploring students' emotional response to these dilemmas, and (c) examining how students perceive the influence of these dilemmas on their professional development. METHODS This is a cross-sectional qualitative study carried out in 2017 that applied thematic template analysis to individual interviews performed with last-year medical students. The interviews followed the drawing of a Rich Picture representing moral dilemmas experienced by medical students at the onset of clinical practice. RESULTS Moral dilemmas have four intertwined dimensions. The first relates to students' struggle to prioritise, balance and apply conflicting moral values; the second comprises the clash between students' inner motivation and the external constraints that limit the moral action; the third refers to the conflict between students' current attitudes with the desired/idealised attitudes of the doctor they intend to become; and the fourth corresponds to weighting conflicting ethical principles during the moral decision. Students' emotional responses are intense and long-lasting, and with a remarkable residue effect, particularly when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both detachment and growth in moral courage. CONCLUSION Moral dilemmas are memorable, complex and emotionally intense experiences that impact the professional development of medical students. Understanding students' moral dilemmas can help educators to devise pedagogical activities to anticipate and reflect on these experiences. These activities should happen under the guidance of a non-judgemental facilitator, capable of listening and legitimating students' thoughts and feelings while providing insights to nurture their professional development.
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Affiliation(s)
- Diego Lima Ribeiro
- Department of Ethics and Emergency MedicineUniversity of CampinasCampinasBrazil
| | - Marcos Costa
- University Medical Center AmsterdamAmsterdamThe Netherlands
| | - Esther Helmich
- Center for Education Development and Research in Health ProfessionsUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Debbie Jaarsma
- Center for Education Development and Research in Health ProfessionsUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Marco Antonio de Carvalho‐Filho
- Center for Education Development and Research in Health ProfessionsUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- ICVS ‐ Life and Health Sciences Research InstituteUniversity of MinhoBragaPortugal
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Pedersen K, Moercke AM, Paltved C, Mors O, Ringsted C. Video cases as tricksters, in medical students´ transition to psychiatric clerkship. A liminal perspective. MedEdPublish (2016) 2021; 10:95. [PMID: 38486587 PMCID: PMC10939659 DOI: 10.15694/mep.2021.000095.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
This article was migrated. The article was marked as recommended. OBJECTIVE This study introduced a lens of liminal theory, drawn from anthropological classical ritual theory, to explore how a preparatory teaching format using video casesinfluenced medical students' patient approaches in their subsequent psychiatric clerkship. The video cases portrayed simulated patient-doctor encounters in diagnostic interview situations and were hypothesized to function as a liminal trickster. METHODS The study applied a qualitative explorative design using individual rich picture interviews. We asked the students to draw their experiences, which we investigated using a semi-structured interview guide designed to capture and unfold the students' perspectives. We explored how students navigated insights from the preparatory teaching in their clerkship using liminal theory concepts in a mixed inductive and deductive thematic analysis. RESULTS The results from 8 rich picture interviews demonstrated that students' ability to navigate insight gained from the video cases in their clerkship varied according to their roles in the clinical diagnostic interview situations. Students having active roles in the diagnostic interview situation adopted a patient-centred focus demonstrating empathic engagement and self-reflexivity related to their learning experiences with the video cases. Students with passive roles described a focus on how to adopt an appropriate appearance and copied the behaviour of the simulated doctors in the video cases. CONCLUSION The liminal ritual theory perspective to explore the influence of preparatory teaching was useful for demonstrating how video cases could affect students' patient-centred learning. Without guidance and active roles in clerkship, medical students' learning experiences may lead to a prolonged liminal phase and may not capitalise on the potentially positive effects of the preparatory teaching. Liminal theory may further inform our understanding of students' learning considering patient cases in educational technology arrangements as tricksters.
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Herrington OD, Clayton A, Benoit L, Prins-Aardema C, DiGiovanni M, Weller I, Martin A. Viral time capsule: a global photo-elicitation study of child and adolescent mental health professionals during COVID-19. Child Adolesc Psychiatry Ment Health 2021; 15:5. [PMID: 33531051 PMCID: PMC7852478 DOI: 10.1186/s13034-021-00359-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/16/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To examine, through photo-elicitation, the personal and professional impact of the COVID-19 pandemic on mental health professionals working with children and adolescents around the globe. METHODS We invited the submission of images collected about the pandemic between May and August 2020. We encouraged participants to yoke personal reflections or voice memos to their images. Using snowball sampling, we began with two invitations, including one to the graduates of a mentorship program continuously hosted since 2004 by the International Association of Child and Adolescent Psychiatry and Allied Professions (IACAPAP). We analyzed de-identified images and anonymized transcripts through iterative coding using thematic analysis informed by rich picture analysis and aided by NVivo software. RESULTS We collected submissions from child and adolescent mental health professionals (n = 134) working in 54 countries spread across the five continents. We identified four overarching domains with component themes that revealed both the commonality and the uniqueness of the pandemic experience around the globe: (1) Place (adjusting to emptiness and stillness; shifting timeframes; blending of spaces); (2) Person (disruption to life rhythms; emotional toll; positives of the pandemic); (3) Profession (changing practices; outreach efforts; guild pride-and guilt); and (4) Purpose (from pandemic to syndemic; from lamenting to embracing; planning toward a better tomorrow). CONCLUSIONS Photo-elicitation provided a disarming and efficient means to learn about individual, regional, and global similarities and differences regarding the professionals charged with addressing the mental health needs of children and adolescents around the globe. These findings may help inform practice changes in post-pandemic times.
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Affiliation(s)
| | - Ashley Clayton
- grid.47100.320000000419368710Department of Psychiatry, Yale School of Medicine, New Haven, CT USA
| | - Laelia Benoit
- grid.7429.80000000121866389Public Health and Sociology, Inserm (Institut National de La Santé et de La Recherche Médicale) and CESP (Centre de recherche en Epidémiologie et Santé des Populations), Paris, France
| | - Cecil Prins-Aardema
- grid.468637.80000 0004 0465 6592GGZ Drenthe (Geestelijke Gezondheids Zorg: Mental Health Care), Beilen, The Netherlands ,grid.4494.d0000 0000 9558 4598Center for Educational Development and Research in Health Sciences (CEDAR), University Medical Center Groningen, Groningen, The Netherlands
| | | | - Indigo Weller
- grid.38142.3c000000041936754XBioethics Program, Harvard University, Cambridge, MA USA
| | - Andrés Martin
- Center for Educational Development and Research in Health Sciences (CEDAR), University Medical Center Groningen, Groningen, The Netherlands. .,Child Study Center, Yale School of Medicine, 230 South Frontage Road, New Haven, CT, 06520-7900, USA.
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Koopman WJ, Watling CJ, LaDonna KA. Autoethnography as a Strategy for Engaging in Reflexivity. Glob Qual Nurs Res 2020; 7:2333393620970508. [PMID: 33283020 PMCID: PMC7683839 DOI: 10.1177/2333393620970508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 01/03/2023] Open
Abstract
Reflexivity is a key feature in qualitative research, essential for ensuring rigor. As a nurse practitioner with decades of experience with individuals who have chronic diseases, now embarking on a PhD, I am confronted with the question “how will my clinical experiences shape my research?” Since there are few guidelines to help researchers engage in reflexivity in a robust way, deeply buried aspects that may affect the research may be overlooked. The purpose of this paper is to consider the affordances of combining autoethnography (AE) with visual methods to facilitate richer reflexivity. Reflexive activities such as free writing of an autobiographical narrative, drawings of clinical vignettes, and interviews conducted by an experienced qualitative researcher were analyzed to probe and make visible perspectives that may impact knowledge production. Two key themes reflecting my values—fostering advocacy and favoring independence and autonomy were uncovered with this strategy.
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Abstract
PURPOSE Faculty development is increasingly acknowledged as an important aspect of health professions education. Its conceptualization has evolved from an individual skills training activity to contemporary notions that draw on an organizational model. This organizational model recognizes relationships and networks as important mediators of knowledge mobilization. Although such conceptual advancements are critical, we lack empirical evidence and robust insights into how social networks function to shape learning in faculty development. The purpose of this study was to understand how informal professional social networks influence faculty development learning in the health professions. METHOD This study used a qualitative social network approach to explore how teaching faculty's relationships influenced their learning about teaching. The study was conducted in 2018 in an undergraduate course at a Canadian medical school. Eleven faculty participants were recruited, and 3 methods of data collection were employed: semistructured interviews, participant-drawn sociograms, and demographic questionnaires. RESULTS The social networks of faculty participants influenced their learning about teaching in the following 4 dimensions: enabling and mobilizing knowledge acquisition, shaping identity formation, expressing vulnerability, and scaffolding learning. CONCLUSIONS Faculty developers should consider faculty's degree of social embeddedness in their professional social networks, as our study suggests this may influence their learning about teaching. The findings align with recent calls to conceptually reorient faculty development in the health professions as a dynamic social enterprise.
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Affiliation(s)
- Heather Buckley
- H. Buckley is clinical assistant professor, Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura Nimmon
- L. Nimmon is scientist, Center for Health Education Scholarship, and associate professor, Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Pipere A, Mārtinsone K, Regzdiņa-Pelēķe L, Grišķeviča I. Sailing Across the Atlantic: An Exploration of the Psychological Experience Using Arts-Based Research. Front Psychol 2020; 11:572028. [PMID: 33162914 PMCID: PMC7591676 DOI: 10.3389/fpsyg.2020.572028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
The reported study pursues the bidimensional objective, namely, (1) to grasp the essence of the psychological experience of a transatlantic journey and (2) to observe the potential of arts-based research for the enhancement of the well-being of sailors. The sample consisted of three males and one female - Latvian citizens, aged 36-68 years, with higher education and different sailing experience. In the context of a case study grounded on arts-based research methods, the freehand drawings of self-portraits or something important during the day were obtained using individual diaries containing daily reports on the sailing experience. After the journey, individual drawings prompted interviews organized for each participant. The results were triangulated with data from the logbook. In their drawings, participants focused more on the environment rather than on self-representation, that is, telling the story about "here and now" in terms of specific time (journey), place (boat), and their relationship with nature, as well as dealing with problems during the trip. The psychological experience of transoceanic sailing matched the three general dimensions (dynamics, context, and content of experience) of the conceptual framework constructed for this study. The three dimensions of experience were equivalently represented in research data; however, only dynamics and context were fully delineated in all theoretical subcategories. As to the potential of arts-based research for the enhancement of sailors' well-being, the findings show both direct and indirect evidence concerning their psychological and existential well-being. Further research is still needed to confirm the findings on a broader scale and in other contexts.
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Affiliation(s)
- Anita Pipere
- Department of Health Psychology and Pedagogy, Riga Stradiņš University, Riga, Latvia
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van der Goot WE, Cristancho SM, de Carvalho Filho MA, Jaarsma ADC, Helmich E. Trainee-environment interactions that stimulate motivation: A rich pictures study. Med Educ 2020; 54:242-253. [PMID: 31885121 PMCID: PMC7065236 DOI: 10.1111/medu.14019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/19/2019] [Accepted: 10/02/2019] [Indexed: 05/15/2023]
Abstract
CONTEXT Staying motivated when working and learning in complex workplaces can be challenging. When complex environments exceed trainees' aptitude, this may reduce feelings of competence, which can hamper motivation. Motivation theories explain how intrapersonal and interpersonal aspects influence motivation. Clinical environments include additional aspects that may not fit into these theories. We used a systems approach to explore how the clinical environment influences trainees' motivation and how they are intertwined. METHODS We employed the rich pictures drawing method as a visual tool to capture the complexities of the clinical environment. A total of 15 trainees drew a rich picture representing a motivating situation in the workplace and were interviewed afterwards. Data collection and analysis were performed iteratively, following a constructivist grounded theory approach, using open, focused and selective coding strategies as well as memo writing. Both drawings and the interviews were used to reach our results. RESULTS Trainees drew situations pertaining to tasks they enjoyed doing and that mattered for their learning or patient care. Four dimensions of the environment were identified that supported trainees' motivation. First, social interactions, including interpersonal relationships, supported motivation through close collaboration between health care professionals and trainees. Second, organisational features, including processes and procedures, supported motivation when learning opportunities were provided or trainees were able to influence their work schedule. Third, technical possibilities, including tools and artefacts, supported motivation when tools were used to provide trainees with feedback or trainees used specific instruments in their training. Finally, physical space supported motivation when the actual setting improved the atmosphere or trainees were able to modify the environment to help them focus. CONCLUSIONS Different clinical environment dimensions can support motivation and be modified to create optimal motivating situations. To understand motivational dynamics and support trainees to navigate through postgraduate medical education, we need to take all clinical environment dimensions into account.
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Affiliation(s)
- Wieke E. van der Goot
- Martini AcademieMartini HospitalGroningenthe Netherlands
- Center for Education Development and Research in health professions (CEDAR)Lifelong Learning, Education and Assessment Research Network (LEARN)University of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Sayra M. Cristancho
- Schulich School of Medicine and DentistryUniversity of Western OntarioLondonOntarioCanada
| | - Marco Antonio de Carvalho Filho
- Center for Education Development and Research in health professions (CEDAR)Lifelong Learning, Education and Assessment Research Network (LEARN)University of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of Emergency MedicineSchool of Medical SciencesUniversity of CampinasCampinasBrazil
| | - A. Debbie C. Jaarsma
- Center for Education Development and Research in health professions (CEDAR)Lifelong Learning, Education and Assessment Research Network (LEARN)University of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Esther Helmich
- Center for Education Development and Research in health professions (CEDAR)Lifelong Learning, Education and Assessment Research Network (LEARN)University of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Goebel EA, Cristancho SM, Driman DK. Pimping in Residency: The Emotional Roller-Coaster of a Pedagogical Method - A Qualitative Study Using Interviews and Rich Picture Drawings. Teach Learn Med 2019; 31:497-505. [PMID: 31084222 DOI: 10.1080/10401334.2019.1610658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Phenomenon: Pimping has become a well-known and distinct form of questioning in medical education, and as a pedagogical method it has both proponents and detractors. Pimping occurs when a teacher (pimper) asks difficult questions of the learner (pimpee), usually in rapid succession. There is a paucity of literature formally studying this technique and its effects on teachers and learners. Our study examines the use of and attitudes toward pimping in a pathology residency program to better understand its perceived value and effectiveness. Approach: Using a qualitative approach, we conducted semistructured interviews with 8 pathology trainees and 9 pathologists. As part of the interview process, we asked participants to draw a rich picture of a pimping encounter. Consistent with this qualitative method, we analyzed data iteratively using constant comparison. Findings: Negative emotions including anxiety and self-doubt dominated among the learners during pimping encounters. For some, these resulted in motivation to study, and for others this was a futile, nonmotivating experience. Most trainees felt that they were being judged during pimping; however, they perceived that the intentions of pimping were not malicious and in their best interests. This was supported by pathologists, who stated that their motivation for pimping was to identify knowledge gaps, thus benefiting the trainee. Insights: Pimping created a dichotomy of emotions within the majority of learners in this study. Negative emotions occurred during pimping encounters; however, following the encounter, pimping was perceived in a more positive light. Recognizing when and how pimping can create negative emotions that may interfere with learning may enable educators to create more consistently meaningful interactions.
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Affiliation(s)
- Emily A Goebel
- Departments of Pathology and Laboratory Medicine, Western University and London Health Sciences Centre, London, Ontario
| | - Sayra M Cristancho
- Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario
| | - David K Driman
- Departments of Pathology and Laboratory Medicine, Western University and London Health Sciences Centre, London, Ontario
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Olmos-Vega FM, Dolmans DHJM, Guzmán-Quintero C, Echeverri-Rodriguez C, Teunnissen PW, Stalmeijer RE. Disentangling residents' engagement with communities of clinical practice in the workplace. Adv Health Sci Educ Theory Pract 2019; 24:459-475. [PMID: 30659426 DOI: 10.1007/s10459-019-09874-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
Maximising the potential of the workplace as a learning environment entails understanding the complexity of its members' interactions. Although some articles have explored how residents engage with supervisors, nurses and pharmacists individually, there is little research on how residents enter into and engage with the broader community of clinical practice (CoCP). To this end, we designed a constructivist grounded theory study that took place at Universidad Javeriana in Bogotá, Colombia. We conducted semi-structured interviews with 13 residents from different training levels and disciplines during the first weeks of their new rotations. During the interviews, we used the Pictor technique as a visual aid to collect data. Using iterative data collection and analysis, constant comparison methods and theoretical sampling, we constructed the final results. When entering a CoCP, residents experienced recurring and intertwined processes including: exploring how their goals and interest are aligned with those of the CoCP; identifying the relevant CoCP members in the workplace environment; and understanding how these members could assist their successful engagement with the community's practices. Residents entered a CoCP with the intention of either having a central or a peripheral trajectory in it. The final resident participation and role resulted from negotiations between the resident and the CoCP members. Optimising workplace learning includes being mindful as to how each member of the healthcare team influence residents' engagement on practice, and on understanding the nuances of residents' participatory trajectories while interacting with them. Understanding such nuances could be key to align CoCPs' learning affordances and residents' goals and intentions.
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Affiliation(s)
- Francisco M Olmos-Vega
- Anaesthesiology Department, Faculty of Medicine, Pontificia Universidad Javeriana, Carrera 7 40-62, Fourth Floor, Bogotá, Colombia.
- Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - Diana H J M Dolmans
- School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Carlos Guzmán-Quintero
- Anthropology Department, Social Sciences Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Camila Echeverri-Rodriguez
- Anaesthesiology Department, Faculty of Medicine, Pontificia Universidad Javeriana, Carrera 7 40-62, Fourth Floor, Bogotá, Colombia
| | - Pim W Teunnissen
- School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- VU University Medical Center, Amsterdam, The Netherlands
| | - Renée E Stalmeijer
- School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Bood ZM, Scherer-Rath M, Sprangers MAG, Timmermans L, van Wolde E, Cristancho SM, Heyning F, Russel S, van Laarhoven HWM, Helmich E. Living with advanced cancer: Rich Pictures as a means for health care providers to explore the experiences of advanced cancer patients. Cancer Med 2019; 8:4957-4966. [PMID: 31278862 PMCID: PMC6718737 DOI: 10.1002/cam4.2342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 11/09/2022] Open
Abstract
Background To provide holistic care to patients with advanced cancer, health care professionals need to gain insight in patients’ experiences across the different domains of health. However, describing such complex experiences verbally may be difficult for patients. The use of a visual tool, such as Rich Pictures (RPs) could be helpful. We explore the use of RPs to gain insight in the experiences of patients with advanced cancer. Methods Eighteen patients with advanced cancer were asked to draw a RP expressing how they experienced living with cancer, followed by a semi‐structured interview. Qualitative content analysis, including the examination of all elements in the drawings and their interrelationships, was used to analyze the RPs, which was further informed by the interviews. Results The RPs clearly showed what was most important to an individual patient and made relations between elements visible at a glance. Themes identified included: medical aspects, the experience of loss, feelings related to loss, support from others and meaningful activities, and integration of cancer in one's life. The added value of RPs lies in the ability to represent these themes in one single snapshot. Conclusions RPs allow for a complementary view on the experiences of advanced cancer patients, as they show and relate different aspects of patients’ lives. A RP can provide health care professionals a visual summary of the experiences of a patient. For patients, telling their story to health care professionals might be facilitated when using RPs.
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Affiliation(s)
- Zarah M Bood
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael Scherer-Rath
- Faculty of Philosophy, Theology, and Religious Studies, Radboud University-Nijmegen, Nijmegen, The Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Liesbeth Timmermans
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ellen van Wolde
- Faculty of Philosophy, Theology, and Religious Studies, Radboud University-Nijmegen, Nijmegen, The Netherlands
| | - Sayra M Cristancho
- Centre for Education Research & Innovation and Department of Surgery, Health Sciences Addition, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - Fenna Heyning
- Association of Topclinical Hospitals STZ, Utrecht, the Netherlands
| | - Silvia Russel
- Independent Artist, Researcher, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Esther Helmich
- Center for Education Development and Research in Health Professions, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Abstract
PROBLEM The traditional clerkship model of brief encounters between faculty and students results in reduced meaningful learning opportunities due to the lack of a relationship that enables repeated observation, supervisor feedback, trust formation, and growth. INTERVENTION Clinical clerkships at our institution were restructured to decrease fragmentation of supervision and foster an educational alliance between faculty and student. A mixed-methods approach was used to study the impact of this curriculum reform on the student experience in the obstetrics and gynecology clerkship. Student participation in patient care was assessed by comparing the number of common obstetric procedures performed before and after clerkship reform. Separate qualitative analyses of comments from student surveys and a faculty focus group revealed themes impacting student involvement. The supervisor-trainee relationship was further investigated by analysis of "rich picture" discussions with students and faculty. CONTEXT Clerkships in the 3rd year of our 4-year undergraduate medical curriculum were converted from an experience fragmented by both didactic activities and multiple faculty supervisors to one with a single supervisor and the elimination of competing activities. OUTCOMES Students in the revised clerkship performed twice the number of obstetric procedures. Objective measures (United States Medical Licensing Examination Step 1 scores, receiving clerkship honors, self-reported interest in obstetrics, and gender) did not correlate with the number of procedures performed by students. Qualitative analysis of student survey comments revealed that procedure numbers were influenced by being proactive, having a supervisor with a propensity to teach (trust), and contextual factors (busy service or competition with other learners). Themes identified by faculty that influenced student participation included relationship continuity; growth of patient care skills; and observed student engagement, interest, and confidence. The quality of the relationship was cited by both students and faculty as a factor influencing meaningful clinical participation. Discussions of "rich pictures" drawn by students and faculty revealed that relationships are influenced by continuity, early alignment of goals, and the engagement and attitude of both student and faculty. LESSONS LEARNED Clinical curricular reforms that strengthen the continuity of the supervisor-trainee relationship promote mutual trust and can result in a more meaningful training experience in less time. Reciprocal engagement and early alignment of goals between supervisor and trainee are critical for creating a positive relationship.
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Affiliation(s)
- J Kevin Dorsey
- a Departments of Internal Medicine and Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Austin M Beason
- b Division of Orthopaedic Surgery, Department of Surgery, Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Steven J Verhulst
- c Department of Medical Microbiology, Immunology and Cell Biology, Center for Clinical Research , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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Sukhera J, Wodzinski M, Teunissen PW, Lingard L, Watling C. Striving While Accepting: Exploring the Relationship Between Identity and Implicit Bias Recognition and Management. Acad Med 2018; 93:S82-S88. [PMID: 30365434 DOI: 10.1097/acm.0000000000002382] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE Implicit biases worsen outcomes for underserved and marginalized populations. Once health professionals are made aware of their implicit biases, a process ensues where they must reconcile this information with their personal and professional identities. The authors sought to explore how identity influences the process of implicit bias recognition and management. METHOD Using constructivist grounded theory, the authors recruited 11 faculty and 10 resident participants working at an academic health science center in Canada. Interviews took place from June to October 2017. Participants took an online version of the mental illness implicit association test (IAT) which provides users with their degree of implicit dangerousness bias toward individuals with either physical or mental illness. Once they completed the IAT, participants were invited to draw a rich picture and interviewed about their picture and experience of taking their IAT. Data were analyzed using constant comparative procedures to develop focused codes and work toward the development of a deeper understanding of relationships among themes. RESULTS Once implicit biases were brought into conscious awareness, participants acknowledged vulnerabilities which provoked tension between their personal and professional identities. Participants suggested that they reconcile these tensions through a process described as striving for the ideal while accepting the actual. Relationships were central to the process; however, residents and faculty viewed the role of relationships differently. CONCLUSIONS Striving for self-improvement while accepting individual shortcomings may provide a model for addressing implicit bias among health professionals, and relational dynamics appear to influence the process of recognizing and managing biases.
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Affiliation(s)
- Javeed Sukhera
- J. Sukhera is assistant professor in psychiatry and paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada, and a PhD candidate in health professions education, Maastricht University, Maastricht, the Netherlands. M. Wodzinski is an MD candidate, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. P.W. Teunissen is professor of workplace learning in healthcare, Faculty of Health Medicine and Life Sciences, Maastricht University, and gynecologist, Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, the Netherlands. L. Lingard is professor, Department of Medicine, and director, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. C. Watling is professor and associate dean for postgraduate medical education, Schulich School of Medicine and Dentistry, Western University, and scientist, Centre for Education Research and Innovation, London, Ontario, Canada
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LaDonna KA, Field E, Watling C, Lingard L, Haddara W, Cristancho SM. Navigating complexity in team-based clinical settings. Med Educ 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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Abstract
Phenomenon: Patients have access to a wide variety of sources of information about their health in their day-to-day contexts. This can sometimes result in discordance between a physician's perception of a patient's health issue and a patient's perception of their health issue. Even after the physician has negotiated an understanding and treatment plan with a patient, subsequent interactions outside the physician-patient encounter may modify the patient's understanding of their health issue. A patient's reinterpretation of his or her health issue can then result in nonadherence of the treatment plan or even alternative treatment plans that the physician perceives as being unsatisfactory. Current models of physician-patient communication do not prepare physicians to manage this phenomenon. Approach: Using an ethnographic and a social network analysis research design, participants' patterns of social interaction around health information were investigated over a yearlong period (2012-2013) in a small rural community in Western Canada. Data included (a) individual interviews, (b) focus group interviews, and (c) field notes. Data were analyzed in a three-stage process: (a) item analysis, (b) pattern analysis, and (c) structural analysis. Findings: The findings highlight how physicians are only one nodal point in patients' broad, multilayered networks of communication. Interactions around health topics were not isolated events but rather occurred in various patterns of social interactions that were longitudinal and iterative. Meaning making around health topics was constructed, shared, elaborated, reconstructed, and interpreted in participants' social networks, as information was distributed through a complex temporal system of interpersonal ties. Insights: Issues concerning physician communication have been a long-standing conversation in the field of medical education. Many competency frameworks have attempted to encompass this core competency in their elaboration of the physician communicator. However, most representations and discussions in the field tend to depict physician communicators as experts who translate their knowledge to patients in a simplified way, in a single moment in time. This study suggests that educational initiatives in physician-patient communication would benefit from contextualizing physicians as part of patients' resource-rich, temporally extended, iterative process of meaning making. This alternative framing has the potential to support physicians' continuing engagement with patients as a meaningful and responsive node in patients' meaning-making networks.
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Affiliation(s)
- Laura Nimmon
- a Centre for Health Education Scholarship, University of British Columbia , Vancouver , British Columbia , Canada
- b Department of Occupational Science and Occupational Therapy , University of British Columbia , Vancouver , British Columbia , Canada
| | - Glenn Regehr
- a Centre for Health Education Scholarship, University of British Columbia , Vancouver , British Columbia , Canada
- c Department of Surgery , University of British Columbia , Vancouver , British Columbia , Canada
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Affiliation(s)
- Charlotte Rees
- Monash Centre for Scholarship in Health Education (MCSHE), Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia.
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Helmich E, Diachun L, Joseph R, LaDonna K, Noeverman-Poel N, Lingard L, Cristancho S. 'Oh my God, I can't handle this!': trainees' emotional responses to complex situations. Med Educ 2018; 52:206-215. [PMID: 29044675 DOI: 10.1111/medu.13472] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 05/12/2017] [Accepted: 09/04/2017] [Indexed: 05/28/2023]
Abstract
CONTEXT Dealing with emotions is critical for medical trainees' professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations. METHODS In an international constructivist grounded theory study, 29 trainees drew two rich pictures of complex clinical situations, one exciting and one frustrating. Rich pictures are visual representations that capture participants' perceptions about the people, situations and factors that create clinical complexity. These pictures were used to guide semi-structured, individual interviews. We analysed visual materials and interviews in an integrated way, starting with looking at the drawings, doing a 'gallery walk', and using the interviews to inform the aesthetic analysis. RESULTS Participants' drawings depicted a range of personal emotions in response to complexity, and disclosed unsettling feelings and behaviours that might be considered unprofessional. When trainees felt confident, they were actively participating, engaged in creative problem-solving strategies, and emphasised their personal involvement. When trainees felt the situation was beyond their control, they described how they were running away from the situation, hiding themselves behind others or distancing themselves from patients or families. CONCLUSIONS A sense of control seems to be a key factor influencing trainees' emotional and behavioural responses to complexity. This is problematic, as complex situations are by their nature emergent and dynamic, which limits possibilities for control. Following a social performative approach to emotions, we should help students understand that feeling out of control is an inherent property of participating in complex clinical situations, and, by extension, that it is not something they will 'grow out of' with expertise.
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Affiliation(s)
- Esther Helmich
- University Medical Center Groningen, Groningen, the Netherlands
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Peters A, Vanstone M, Monteiro S, Norman G, Sherbino J, Sibbald M. Examining the Influence of Context and Professional Culture on Clinical Reasoning Through Rhetorical-Narrative Analysis. Qual Health Res 2017; 27:866-876. [PMID: 27222036 DOI: 10.1177/1049732316650418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
According to the dual process model of reasoning, physicians make diagnostic decisions using two mental systems: System 1, which is rapid, unconscious, and intuitive, and System 2, which is slow, rational, and analytical. Currently, little is known about physicians' use of System 1 or intuitive reasoning in practice. In a qualitative study of clinical reasoning, physicians were asked to tell stories about times when they used intuitive reasoning while working up an acutely unwell patient, and we combine socio-narratology and rhetorical theory to analyze physicians' stories. Our analysis reveals that in describing their work, physicians draw on two competing narrative structures: one that is aligned with an evidence-based medicine approach valuing System 2 and one that is aligned with cooperative decision making involving others in the clinical environment valuing System 1. Our findings support an understanding of clinical reasoning as distributed, contextual, and influenced by professional culture.
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Affiliation(s)
| | | | | | - Geoff Norman
- 1 McMaster University, Hamilton, Ontario, Canada
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Cristancho S, Lingard L, Forbes T, Ott M, Novick R. Putting the puzzle together: the role of 'problem definition' in complex clinical judgement. Med Educ 2017; 51:207-214. [PMID: 27943366 PMCID: PMC5578752 DOI: 10.1111/medu.13210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/20/2016] [Accepted: 08/15/2016] [Indexed: 05/16/2023]
Abstract
CONTEXT We teach judgement in pieces; that is, we talk about each aspect separately (patient, plan, resources, technique, etc.). We also let trainees figure out how to put the pieces together. In complex situations, this might be problematic. Using data from a drawing-based study on surgeons' experiences with complex situations, we explore the notion of 'problem definition' in real-world clinical judgement using the theoretical lens of systems engineering. METHODS 'Emergence', the sensitising concept for analysis, is rooted in two key systems premises: that person and context are inseparable and that what emerges is an act of choice. Via a 'gallery walk' we used these premises to perform analysis on individual drawings as well as cross-comparisons of multiple drawings. Our focus was to understand similarities and differences among the vantage points used by multiple surgeons. RESULTS In this paper we challenge two assumptions from current models of clinical judgement: that experts hold a fixed and static definition of the problem and that consequently the focus of the expert's work is on solving the problem. Each situation described by our participants revealed different but complementary perspectives of what a surgical problem might come to be: from concerns about ensuring standard of care, to balancing personal emotions versus care choices, to coordinating resources, and to maintaining control while in the midst of personality clashes. CONCLUSION We suggest that it is only at the situation and system level, not at the individual level, that we are able to appreciate the nuances of defining the problem when experts make judgements during real-world complex situations.
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Affiliation(s)
| | | | | | - Michael Ott
- University of Western Ontario, London, Ontario, Canada
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