Medical Education最新文献

Introduction: Health professions training programmes face increasing reports of professionalism lapses, which can delay, or end, trainee progression. How programmes respond to professionalism lapses to facilitate professional identity development has not been clarified. The objective of this study is to identify factors that facilitate and impair transformations around professionalism lapses in health professions training programmes.

Methods: We conducted a qualitative study interviewing 5 faculty and 20 trainees with firsthand or secondhand experience with professionalism lapses from a range of health professions training programmes at McMaster University. Using reflexive thematic analysis, we coded verbatim transcripts informed by the lenses of social and transformative learning theories. We constructed themes through iterative and comparative analysis, seeking meaningful variation across professions and triangulating faculty and trainee perspectives.

Results: Four themes were constructed. First, lapses are in the eye of the beholder with personal definitions intersecting with institutional and situation norms. Difficulties exist in recognising and convincing trainees to respond to lapses that are perceived to be minor or subject to interpretation. Second, responses to professionalism lapses occurred within power hierarchies, which impacted how trainees reacted to the remediation process, risked superficial trainee responses to concerns and led to concerns around inequitable treatment in how standards were applied. Third, fostering transformation involves building trainee confidence, agency, trust and engagement. Focused support and advocacy for trainees can empower and promote agency in tackling disorienting lapses. Fourth, perspective shifts involve deep engagement over time, including but not limited to self-reflection, structured discussion and seeking support.

Discussion: Identifying and addressing professionalism lapses is complex and requires nuanced and contextual exploration of personal, institutional and situational dynamics at play. By fostering environments that promote genuine reflection and dialogue and focus on building trainee confidence, agency, trust and engagement, health professions training programmes can better support trainees in navigating these complex situations and contribute to the broader goal of socialising to a professional culture and practice.

Introduction: Research on feedback has shifted emphasis away from its 'delivery' to consideration of the interaction between individual learners and their 'feedback provider'. The complexity inherent in determining whether feedback is perceived as valuable by learners, however, can quickly overwhelm educators if every interaction must be considered completely idiosyncratic. We, therefore, require a better understanding of variability in the ways in which feedback is perceived. To that end, we ran a discrete choice experiment aimed at determining residents' preferences and whether discernible patterns exist across learners regarding factors that influence perceptions of feedback's learning value.

Methods: We performed a discrete choice experiment in which respondents were asked to read a clinical case and select repetitively between two feedback scenarios that differed according to six attributes identified from the literature as influencing feedback credibility: Dialogue, Focus, Relationship, Situation, Source and Valence. By systematically varying the levels of each attribute contained in the scenarios and asking residents to choose which from each pair they deemed more valuable for learning, a mixed logit model and latent class analysis could be applied to determine learners' feedback preferences and whether clusters of preference exist.

Results: Ninety-five elderly care medicine residents in the Netherlands completed the questionnaire. Their responses indicated that Valence, Dialogue, Relationship and Focus each accounted for about 20% of their preferences regarding the type of feedback perceived to offer the most learning value. Source and Situation were less influential, each accounting for 11% of the choices made. A latent class model with three clusters of respondents best accounted for the heterogeneity in feedback preferences. A total of 62% of respondents could be assigned to one of the three profiles with at least 80% probability. None of the respondents' characteristics (seniority, residency programme nor sex) were related to the feedback preference profile.

Discussion: Our findings suggest that 'how' feedback is provided has a greater influence on perceived learning value than who provides it. That said, variability exists in resident perceptions with no evidence (as yet) of factors that predict individual preferences. As such, tailoring to the needs and reactions of individual learners is likely to require open and ongoing conversations, and we recommend using the learner profiles generated through this study as a starting point because they provide classifications that could facilitate effective connections for the majority of residents.

Background: Illness presenteeism (IP)-characterized by individuals working despite being sick-is a prevalent and complex phenomenon among physicians and trainees amidst competing priorities within medicine. The COVID-19 pandemic and growing attention to physician and trainee well-being have sparked renewed interest in IP. We conducted a scoping review to explore what is known about IP: more specifically, how IP is perceived, what approaches have been used to study the phenomenon and how it might have changed through the COVID-19 pandemic.

Method: The Arksey and O'Malley scoping review framework was used to systematically select and summarize the literature. Searches were conducted across four databases: Medline, Embase, PsycInfo and Web of Science. Quantitative and thematic analyses were conducted.

Results: Of 4277 articles screened, 45 were included. Of these, four were published after the onset of the COVID-19 pandemic. All studies framed IP as problematic for physicians, patients and health care systems. Dominant sociocultural drivers of IP included obligations towards patients and colleagues and avoiding the stigma of appearing vulnerable or even temporarily weak. Structural factors included heavy workload, poor access to health services and lack of sick leave policies for physicians. The pandemic does not appear to have affected IP-related causes or behaviours. Proposed solutions included both educational interventions and policy-driven changes.

Conclusions: Despite being viewed in the literature as largely negative, IP remains highly prevalent among physicians and trainees. Our review highlights that IP among physicians is fraught with tensions: while IP seemingly contradicts certain priorities such as physician wellbeing, IP may be justified by fulfilling obligations to patients and colleagues. Future work should examine IP through diverse theoretical lenses to further elucidate its complexities and inform nuanced individual and systems-level interventions to minimize the negative consequences of IP.

Multiculturalism should celebrate diversity, but history shows it often deepens divides. From colonial scars to modern immigration policies, Khan outines the risks of using it as a tool for division, not unity.

In healthcare settings, effective communication between clinicians and patients is a critical skill that promotes optimal care and health outcomes. However, in medical education, there has been relatively little emphasis on developing students' skills to deal with a variety of communication scenarios they may experience in their practice. These early encounters in medical education are critical, as they shape behaviour patterns that can continue into residency and beyond. As a result, there is a need to develop innovative pedagogical approaches that help students gain self-confidence in their communication skills and cultivate empathy in their interactions with patients, families and colleagues. Medical improvisation offers promise as an adaptation of improvisational theatre principles and role play to improve communication and teamwork in medical practice.¹

To address the challenge of effective clinical communications with patients, families and co-workers, our health humanities faculty implemented an innovative course entitled ‘Medical Improv’ as a selection for the required MS4 elective. The course offers medical students an introduction to the basic skills of improvisation and an understanding of how they can be used in a variety of clinical settings. This approach has been shown to help students respond to unexpected events, address patient concerns and communicate more confidently.¹ Examples of course activities include: warm-up exercises involving teamwork, storytelling, body movement and mirroring; structured role playing to explore the non-verbal aspects of patient-clinician communication; and writing about how a challenging medical school situation could be addressed with improv techniques. The course includes eight 2.5-hour sessions within one semester.

Over the past year, the Medical Improv course has consistently resulted in nearly full enrollment (24 students). In both written course evaluations and oral feedback, students described how the use of improvisation in their class activities could improve their communication skills in their clinical practice. Students also developed insight into how medical improv training can enhance awareness of environmental factors such as the room set-up, which may influence the clinical encounter.

Students kept a reflective journal that indicated a progressive development of understanding the interrelations between communication skills, mindfulness, empathy, teamwork and patient care. The course helps students develop communication, listening and observational skills that can contribute to a more grounded and robust professional identity as well as more effective and empathic interactions with both patients and co-workers. Future studies will examine how this training might help to mitigate stress and burnout in the clinical setting.

This project has been approved by institutional review boards at Penn State College of Medicine.

Context: At the beginning of clinical practice, medical students face complex end-of-life (EoL) decisions, such as limiting life-sustaining therapies, which may precipitate emotionally charged moral dilemmas. Previous research shows these dilemmas may cause identity dissonance and impact students' personal and professional development. Despite the prevalence of such dilemmas, medical educators have limited insight into how students navigate these often emotional experiences. This study explores how medical students make sense of and deal with moral dilemmas lived during EoL's care.

Methods: This cross-sectional qualitative study used thematic analysis (Braun and Clarke) to analyse interviews with 11 Brazilian final-year medical students. The interviews followed the drawing of a rich picture representing moral dilemmas experienced by medical students when engaging with EoL care. The reporting of this study follows the Standards for Reporting Qualitative Research (SRQR).

Results: Participants highlighted four main themes when engaging with EoL care: 'experiencing death', 'making decisions at the end-of-life', 'connecting versus detaching: an upsetting dilemma' and 'being transformed'. They described the emotional overwhelm of experiencing death and the uncertainty in navigating EoL decisions. The central moral dilemma faced was whether to connect with or detach from patients. This dilemma was lived in the context of a hidden curriculum that preaches emotional distancing as a coping mechanism. Developing the moral courage to overcome this barrier and choosing to connect became a transformative experience, significantly impacting their personal and professional development and reinforcing their commitment to patient-centred care.

Conclusion: Connecting with patients in EoL care involves breaking cultural norms to establish meaningful connections with patients aiming for compassionate care. This process may lead to identity dissonance and also represents an opportunity for transformative learning. Educators can support this transformative process by legitimating students' connections with patients, teaching emotional regulation strategies, and leveraging personal experiences to foster trust.

Introduction: Diagnostic errors are often attributed to erroneous selection and interpretation of patients' clinical information, due to either cognitive biases or knowledge deficits. However, whether the selection or processing of clinical information differs between correct and incorrect diagnoses in written clinical cases remains unclear. We hypothesised that residents would spend more time processing clinical information that was relevant to their final diagnosis, regardless of whether their diagnosis was correct.

Methods: In this within-subjects eye-tracking experiment, 19 internal or emergency medicine residents diagnosed 12 written cases. Half the cases contained a correct diagnostic suggestion and the others an incorrect suggestion. We measured how often (i.e. number of fixations) and how long (i.e. dwell time) residents attended to clinical information relevant for either suggestion. Additionally, we measured confidence and time to diagnose in each case.

Results: Residents looked longer and more often at clinical information relevant for the correct diagnostic suggestion if they received an incorrect suggestion and were able to revise this suggestion to the correct diagnosis (dwell time: M: 6.3 seconds, SD: 5.1 seconds; compared to an average of 4 seconds in other conditions; number of fixations: M: 25 fixations, SD: 20; compared to an average of 16-17 fixations). Accordingly, time to diagnose was longer in cases with an incorrect diagnostic suggestion (M: 86 seconds, SD: 47 seconds; compared to an average of 70 seconds in other conditions). Confidence (range: 64%-67%) did not differ depending on residents' accuracy or the diagnostic suggestion.

Discussion: Selectivity in information processing was not directly associated with an increase in diagnostic errors but rather seemed related to recognising and revising a biased suggestion in favour of the correct diagnosis. This could indicate an important role for case-specific knowledge in avoiding biases and diagnostic errors. Future research should examine information processing for other types of clinical information.

Purpose: Sense of belonging supports academic achievement and encourages career endurance. The purpose of this study was to characterize what individual and institutional factors influence one's sense of belonging by describing the experiences of underrepresented in medicine (UIM) paediatric and internal medicine-paediatric residents in the United States.

Method: The authors conducted a national survey of paediatric and internal medicine-paediatric residents. The 23-item anonymous web-based survey was distributed between October 2020 and January 2021 and included questions on socio-demographic characteristics and individual perceptions on sense of belonging, value, common mission or values at a program or institution and respect. The authors used linear mixed models and fitted regression models to examine individual factors and environmental factors that impact sense of belonging, value and respect.

Results: Across 29 residency programs, 938 (53%) of 1748 residents completed the survey. One hundred sixty-seven (18%) self-identified as UIM. UIM residents had a lower sense of belonging than non-UIM residents [mean (SD) 3.6 (0.87) vs. 4.0 (0.57)]. Black/AA and Hispanic/Latinx residents had the lowest sense of belonging [3.5 (0.82) and 2.8 (0.93), respectively]. UIM residents demonstrated decreased sense of belonging in programs that lacked bias training and where peers discriminated against them. Sense of belonging was increased in programs where they perceived a sense of support, respect or values alignment. Surprisingly, individual UIM resident sense of belonging was not improved by having more UIM residents in a program.

Conclusion: UIM paediatric residents experience a decreased sense of belonging during training. Programs can support sense of belonging for UIM residents by demonstrating respect and support for them and by offering systems for bias training and reporting bias and discrimination. Recruiting a greater number of UIM trainees remains important; however, compositional diversity alone does not improve a sense of belonging for UIM residents. There is continued need for structural/institutional change, including addressing institutional culture and structural racism.