A phenomenological study of italian students’ responses to professional dilemmas. A cross-cultural comparison

Phenomenon: Medical professionalism is a complex construct, based in social and cultural influences, yet little research has been done to show how culture influences the behaviors and attitudes of medical students. We presented Italian students with the same professional dilemmas used in a previous Canadian and Taiwanese cross-cultural study to look for similarities and differences and detect elements of Italian culture that influenced how students responded to dilemmas. The aim was to provide medical educators with some insights into students’ behavioral strategies and feelings when faced with a professional dilemma. Approach: Using Giorgi’s method, we performed a phenomenological analysis of 15 interviews of Italian medical students who responded to standardized video scenarios representing professional dilemmas. These videos were used in Canada and Taiwan and were translated into Italian. All students were from the same degree course, at Year 6, and were recruited on a voluntary basis at the beginning of the Internal Medicine course. Interview transcripts were anonymized before analysis. Findings: Scenarios were perceived as realistic and easy to envision in Italy. Four themes emerged: establishing priority among principles, using tactics to escape the dilemma, defending the self, and defending the relationships. When compared with previous studies, we noted that Italian students did not mention the principles of reporting inappropriate behavior, seeking excellence, or following senior trainees’ advice. Insights: This is the first cross-cultural study of professionalism that involves a Mediterranean country and the observed differences could be interpreted as expressions of Italian cultural traits: distrust toward authority and a cooperative rather than competitive attitude. These findings have practical implications for educators to design and run curricula of professionalism with culturally appropriate topics. They highlight the need for more cross-cultural research

Appréhension ou évitement : l’expérience des résidents en médecine interne par rapport aux procédures invasives au chevet du patient

Background: Internal Medicine (IM) residents are required to perform bedside procedures for diagnostic and therapeutic purposes. Residents’ experiences with procedures vary widely, for unclear reasons. Objective: To explore IM residents’ experiences with performing bedside procedures and to identify barriers and facilitators to obtaining sufficient experience. Methods: Using an inductive, thematic approach, we conducted five individual semi-structured interviews and one focus group with seven IM residents (12 residents in total) during the 2017-2018 academic year at a Canadian tertiary care centre. We used iterative, open-ended questions to elicit residents’ experiences, and barriers and facilitators, to performing bedside procedures. Transcripts were analyzed for themes using Braun and Clarke’s method.  Results: We identified four themes 1) Patient-specific factors such as body habitus and procedure urgency; 2) Systems factors such as time constraints and accessibility of materials; 3) Faculty factors including availability to supervise, comfort level, and referral preferences, and 4) Resident-specific factors including preparation, prior experiences, and confidence. Some residents expressed procedure-related anxiety and avoidance. Conclusion: Educational interventions aimed to improve procedural efficiency and ensure availability of supervisors may help facilitate residents to perform procedures, yet may not address procedure-related anxiety. Further study is required to understand better how procedure-averse residents can gain confidence to seek out procedures.Contexte : Les résidents en médecine interne (MI) sont amenés à effectuer des procédures au chevet du patient à des fins diagnostiques et thérapeutiques. Les expériences des résidents par rapport à ces procédures varient considérablement, et nous ne savons pas pourquoi.Objectif : Explorer les expériences des résidents en médecine interne en matière d’interventions au chevet du patient et recenser les facteurs qui entravent ou, au contraire, facilitent l’acquisition d’une expérience suffisante.Méthodes : En utilisant une approche inductive et thématique, nous avons mené cinq entretiens individuels semi-structurés et un groupe de discussion avec sept résidents IM (12 résidents au total) dans un centre de soins tertiaires canadien au cours de l’année universitaire 2017-2018. Nous avons utilisé des questions ouvertes itératives pour interroger les résidents sur leur expérience d’intervention au chevet des patients, ainsi que sur les obstacles et les facilitateurs de ces interventions. Les transcriptions ont été analysées pour dégager des thèmes selon la méthode de Braun et Clarke. Résultats : Nous avons relevé quatre thèmes : 1) les facteurs spécifiques aux patients comme l’habitus corporel et l’urgence de l’intervention; 2) les facteurs systémiques comme les contraintes de temps et l’accès au matériel; 3) les facteurs liés aux enseignants, notamment leur disponibilité pour superviser, le fait d’être à l’aise avec eux et leurs préférences en matière de référence; et 4) les facteurs spécifiques aux résidents, à savoir la préparation, les expériences antérieures et la confiance. Certains résidents ont déclaré vivre de l’anxiété face aux procédures et les éviter.Conclusion : Les initiatives éducatives visant à améliorer l’efficacité des procédures et à assurer la disponibilité de superviseurs peuvent faciliter leur réalisation par les résidents, mais elles ne peuvent pas atténuer l’anxiété que ces interventions suscitent chez ces derniers. Des études supplémentaires sont nécessaires pour trouver des façons d’accroître la confiance des résidents qui sont réticents face aux interventions au chevet du patient

Anticipation or avoidance: internal medicine resident experiences performing invasive bedside procedures

Background: Internal Medicine (IM) residents are required to perform bedside procedures for diagnostic and therapeutic purposes. Residents’ experiences with procedures vary widely, for unclear reasons. Objective: To explore IM residents’ experiences with performing bedside procedures and to identify barriers and facilitators to obtaining sufficient experience. Methods: Using an inductive, thematic approach, we conducted five individual semi-structured interviews and one focus group with seven IM residents (12 residents in total) during the 2017-2018 academic year at a Canadian tertiary care centre. We used iterative, open-ended questions to elicit residents’ experiences, and barriers and facilitators, to performing bedside procedures. Transcripts were analyzed for themes using Braun and Clarke’s method.  Results: We identified four themes 1) Patient-specific factors such as body habitus and procedure urgency; 2) Systems factors such as time constraints and accessibility of materials; 3) Faculty factors including availability to supervise, comfort level, and referral preferences, and 4) Resident-specific factors including preparation, prior experiences, and confidence. Some residents expressed procedure-related anxiety and avoidance. Conclusion: Educational interventions aimed to improve procedural efficiency and ensure availability of supervisors may help facilitate residents to perform procedures, yet may not address procedure-related anxiety. Further study is required to understand better how procedure-averse residents can gain confidence to seek out procedures

An Agenda for Increasing Grant Funding of Emergency Medicine Education Research

Funding is a perennial challenge for medical education researchers. Through a consensus process, the authors developed a multifaceted agenda for increasing funding of education research in emergency medicine ( EM ). Priority agenda items include developing resources to increase the competitiveness of medical education research faculty in grant applications, identifying means by which departments may bolster their faculty's grant writing success, taking long‐term steps to increase the number of grants available to education researchers in the field, and encouraging a shift in cultural attitudes toward education research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/95395/1/acem12041.pd

Promoting inclusivity in health professions education publishing

A taskforce established by Medical Education asks readers to engage in discussion about how the journal and field can do better to ensure that health professional education publishing is inclusive of diverse knowledge and perspectives.https://onlinelibrary.wiley.com/journal/13652923hj2023School of Health Systems and Public Health (SHSPH

Duty hours as viewed through a professionalism lens

Abstract Understanding medical professionalism and its evaluation is essential to ensuring that physicians graduate with the requisite knowledge and skills in this domain. It is important to consider the context in which behaviours occur, along with tensions between competing values and the individual’s approach to resolving such conflicts. However, too much emphasis on behaviours can be misleading, as they may not reflect underlying attitudes or professionalism in general. The same behaviour can be viewed and evaluated quite differently, depending on the situation. These concepts are explored and illustrated in this paper in the context of duty hour regulations. The regulation of duty hours creates many conflicts that must be resolved, and yet their resolution is often hidden, especially when compliance with or violation of regulations carries significant consequences. This article challenges attending physicians and the medical education community to reflect on what we value in our trainees and the attributions we make regarding their behaviours. To fully support our trainees’ development as professionals, we must create opportunities to teach them the valuable skills they will need to achieve balance in their lives. [P]rofessionalism has no meaningful existence independent of the interactions that give it form and meaning. There is great folly in thinking otherwise. Hafferty and Levinson (2008)[1] Understanding and evaluating professionalism is essential to excellence in medical education and is mandated by organizations that oversee medical training [2]. Historically, attention has been focused largely on the professionalism of individual students or residents, at least for the purposes of evaluation. Yet there is now a growing appreciation that professionalism can be defined, understood, and evaluated from multiple perspectives [3]. Importantly, context has been recognized as critical to shaping trainees’ behaviours, and hence as important to our understanding of them [4]. A restriction in duty hours for trainees is clearly an important environmental and contextual factor to consider in evaluating professional behaviour. In this paper I will review some key issues with respect to understanding and evaluating professionalism, and then discuss these in the context of duty hour reform. Readers should note that this is not intended to be a comprehensive review of the literature of either professionalism or duty hour reform, but rather a critical narrative review that uses selected articles

The Disavowed Curriculum: Understanding Student\u27s Reasoning in Professionally Challenging Situations

CONTEXT: Understanding students\u27 perceptions of and responses to lapses in professionalism is important to shaping students\u27 professional development. OBJECTIVE: Utilize realistic, standardized professional dilemmas to obtain insight into students\u27 reasoning and motivations in real time. DESIGN: Qualitative study using 5 videotaped scenarios (each depicting a student placed in a situation which requires action in response to a professional dilemma) and individual interviews, in which students were questioned about what they would do next and why. SETTING: University of Toronto. PARTICIPANTS: Eighteen fourth-year medical students; participation voluntary and anonymous. MAIN OUTCOME MEASURE: A model to explain students\u27 reasoning in the face of professional dilemmas. RESULTS: Grounded theory analysis of interview transcripts revealed that students were motivated to consider specific actions by referencing a Principle (an abstract or idealized concept), an Affect (a feeling or emotion), or an Implication (a potential consequence of suggested actions). Principles were classified as avowed as ideals of our profession (e.g., honesty or disclosure), or unavowed (unacknowledged or undeclared, e.g., obedience or allegiance). Implications could also be avowed (e.g., concerning patients) or unavowed (e.g., concerning others); but students were predominantly motivated by considering disavowed implications: those pertaining to themselves (e.g., concern for grades, evaluations, or reputation), which are actively denied by the profession and discouraged as being inconsistent with altruism. CONCLUSIONS: This disavowed curriculum has implications for education, feedback, and evaluation. Instead of denying their existence, we should teach students how to negotiate and balance these unavowed and disavowed implications and principles, in order to help them develop their own professional stance

To Be and Not to Be: The Paradox of the Emerging Professional Stance

PURPOSE: Understanding how students resolve professional conflict is essential to teaching and evaluating professionalism. The purpose of this study was to refine an existing coding structure of rationalizations of student behaviour, and to further our understanding of students\u27 reasoning strategies in the face of perceived professional lapses. METHODS: Anonymous essays were collected from final year medical students at two universities. Each essay included a description of a specific professional lapse, and a consideration of how the lapse was dealt with. Essays were analysed using grounded theory. The resulting coding structure was applied using NVivo software. RESULTS: Twenty essays, containing 147 instances of articulated reasoning, were included. Three major categories (and several subcategories) of reasoning strategies emerged: Narrative Attitude (deflection or reflection), Dissociation (condescension or identity mobility), and Engagement (with associated action or no action). This data set revealed a wider range of Narrative Attitude than in the original study, confirmed the dominance of Dissociation as a reasoning strategy, and, perhaps paradoxically, also revealed significant evidence of action on the part of the students (predominantly directed towards dealing with the consequences of a lapse or confronting the lapser). Most of these actions were perceived to be ineffective. CONCLUSIONS: Encountering a professional lapse can be a paradoxical and profoundly disordering experience for students. When students report these experiences, they invoke reasoning strategies that enable them to re-story the lapse. Their methods of re-storying provide insight into the double-binds that students experience, their efforts to transcend these double-binds, and, through these, their emerging professional stance

« Obtenir la décision du patient sur la réanimation » : la perception des résidents quant à la discussion sur les objectifs de soins avant et après une formation en ligne

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.Contexte : Les résidents sont souvent amenés à discuter des objectifs de soins (ODS) avec les patients et leurs familles afin d’explorer les valeurs et les préférences des patients et d’élaborer des plans de traitement centrés sur le patient. Cependant, certaines études montrent que le curriculum caché peut favoriser la mauvaise communication et l’orientation de la discussion selon les priorités du médecin. Nous avions déjà conçu un module d’apprentissage en ligne visant à enseigner une approche centrée sur le patient lors des discussions sur les ODS. Ici, nous explorons l’expérience des résidents et la façon dont ce module pourrait contrecarrer l’impact du curriculum caché sur leurs perceptions et leurs approches dans le cadre de ces discussions. Méthodes : Onze résidents de première année en médecine interne de l’Université de Toronto ont participé à des entretiens semi-structurés avant et après avoir suivi le module. Les thèmes ont été définis en appliquant les principes de la théorie ancrée constructiviste. Résultats : Avant de suivre le module, les résidents ont évoqué les pressions institutionnelles et hiérarchiques qu’ils subissent pour obtenir une décision de la part du patient quant à la non-réanimation, les obligeant à diriger la discussion sur les ODS et à l’axer sur la définition du statut de code, la documentation et l’efficacité. Les contradictions entre le programme officiel et le curriculum caché entraînaient chez eux une dissonance et une détresse émotionnelles. En revanche, après avoir terminé la formation, les résidents ont décrit de nouvelles conceptualisations et approches de la discussion sur les ODS, plutôt centrées sur le patient, grâce auxquelles ils se sentent habilités à contester le dictat du médecin quant aux sujets à aborder dans la discussion. Ce changement s’explique par un meilleur alignement de la nouvelle approche sur les valeurs éthiques qu’ils ont intériorisées, une plus grande tolérance à l’incertitude et à la complexité des décisions concernant les ODS et une amélioration des rencontres cliniques dans la pratique. Conclusion : Un module d’apprentissage en ligne axé sur l’enseignement d’une approche fondée sur les données probantes et centrée sur le patient pour les discussions sur les ODS semble favoriser un changement de perspective et d’approche chez les résidents, qui aurait pour effet d’atténuer indirectement l’influence du curriculum caché et d’améliorer la qualité de la communication et des soins