De-fuzzification of reflection in the education of health professionals

Our educational institutions are mandated to equip future physicians and other health care professionals with the scientific, craft, and inter-personal knowledge and skills to meet the demands of contemporary clinical practice. Clinicians must acquire advanced communication skills, develop the ability to manage complex situations, make appropriate use of medical knowledge and technology, and problem-solve through the exercise of refined judgment. The ability to reflect in and on situations of this nature is considered a necessary professional aptitude in order to ensure effective and compassionate whole person care. Notwithstanding the general acceptance of these premises, ‘reflection’ remains a fuzzy concept. It is a polysemous term that has proved difficult to define and has attracted to itself numerous false claims and unfulfilled promises. Excellence in reflective abilities is notoriously difficult to recognize in another individual and it may not be ‘teachable’. Furthermore, there have been recurring doubts as to the feasibility of meaningfully assessing reflection.We intend to explore these issues in this session. We will demonstrate how reflection can be role-modeled and inculcated. Instructional Methods This will be an interactive workshop. Learning Objectives     By the end of the workshop, participants will be able to:• clarify the concept of reflection and understand its application to the education of health professionals• discuss a framework, including specific methods, for the structuring and deployment of an educational program aimed at promoting reflection

"I wish I’d laid my hand on her shoulder". Fostering compassion in first-year medical students

In order to care for sick people as whole persons, health personnel need awareness of how sickness afflicts human beings, and how health professionals affect patients’ ability to deal with disease and suffering. In medical education there is a well-documented dearth of teaching and learning about emotions and relational healing mechanisms. Medical students are not systematically educated in the “existential anatomy” of persons, and how to deal productively with uncertainty, embarrassment and helplessness.In this highly participatory workshop, a concrete teaching method for first-year medical students, developed in Norway, will be shared. The method, called PASKON (“patient contact”) is anchored within a theoretical framework related to Whole Person Care, which is currently taught at McGill.Central to PASKON is the encounter between novice medical students and very sick volunteers, both in the patients’ homes and in the classroom. Having to enter the intimacy sphere of a stranger, and be acknowledged as a health professional without feeling like one, is an orchestrated rite of passage that generates strong emotions and a wealth of material for reflection. More experienced students coach the first-years and assess their reflective essays.The workshop will highlight the rationale for working with relationships, emotion and awareness in medical students. Participants will then be given roles as patients or students, and guided through a simulated session of PASKON, and reflections on the method and its potential applications

Shame in medical education: A mindful approach

Shame is a ubiquitous and potentially damaging emotion with many nuances (embarrassment, humiliation, disgrace, remorse, ridicule etc.). It can be defined as “a state of experiencing oneself as devalued, diminished and an object of derision in the mind of another or others, which when internalized textures a sense of oneself”. Shame regulates social behaviour by penalizing deviations from the norm, and rewarding conformity. The influence of shame on physicians and medical learners is conspicuously absent from the literature on emotional challenges in medicine. The dearth of research on shame is not surprising given that “it is shameful and humiliating to admit that one has been shamed and humiliated.” (Lazare, 1987) Existing literature highlights the harmful effects of shame on both physicians and learners. Humiliation is detrimental to student well-being and can lead to feelings of self-doubt, alienation and inferiority, triggers of perfectionism and loss of empathy. Practicing physicians are prone to shame if their authority is undermined, and may exhibit dismissive, defensive, or aggressive behaviors in the face of criticism, patient conflict or disagreements with colleagues. This workshop will explore mechanisms and implications of shame in medicine and medical education. We will present results from interviews with Norwegian medical students, and use an empirically validated approach called Mindful Practice to investigate challenging themes facing health professionals. This approach utilizes critical awareness (investigating the sources of shame), shared dialogue (reflecting on the personal impact of such experiences) and elements of appreciative inquiry (identifying individual qualities that mitigate negative effects)

Shame in medical clerkship: “You just feel like dirt under someone’s shoe”

Introduction This study explores how senior medical students’ experience and react to shame during clinical placements by asking them to reflect on (1) manifestations of shame experiences, (2) situations and social interactions that give rise to shame, and (3) perceived effects of shame on learning and professional identity development. Methods In this interpretive study, the authors recruited 16 senior medical students from two classes at a Norwegian medical school. In three focus group interviews, participants were invited to reflect on their experiences of shame. The data were analyzed using systematic text condensation, producing rich descriptions about students’ shame experiences. Results All participants had a range of shame experiences, with strong emotional, physical, and cognitive reactions. Shame was triggered by a range of clinician behaviours interpreted as disinterest, disrespect, humiliation, or breaches of professionalism. Shame during clinical training caused loss of confidence and motivation, worries about professional competence, lack of engagement in learning, and distancing from shame-associated specialties. No positive effects of shame were reported. Discussion Shame reactions in medical students were triggered by clinician behaviour that left students feeling unwanted, rejected, or burdensome, and by humiliating teaching situations. Shame had deleterious effects on motivation, learning, and professional identity development. This study has implications for learners, educators, and clinicians, and it may contribute to increased understanding of the importance of supportive learning environments and supervisors’ social skills within the context of medical education.publishedVersio

Medisinsk profesjonalitet: Mestring av legeyrket

When the doctor uses theoretical knowledge, clinical skills, and clinical communication in a way that takes care of the patient, this may be called professionalism. The article aims to show that medical professionalism, in all specialities, may be understood and taught through the two complex concepts “leadership” and “patient-centred medicine”.The article is built on a literature-search with a selection of articles based on the authors’ experience in the field.Leadership is an implicit part of clinical work. The concept gives a perspective on the solution of clinical problems and gives a frame for understanding interaction in consultations and in other professional relations. The doctor personal leadership actualizes professional tutoring as part of the education.Models for patient-centred medicine have emphasized the doctor’s attitudes, skills, and use of linguistic means, and they have deepened the doctor’s understanding for exploring the patient’s problem. Newer models also discuss the doctor’s actions and therapeutic actions and underscorethe leader-role in series of decision-making moments in the consultation. Patient-centred clinical work should be based on an understanding of the doctor as an active co-editor and co-producer of the patient’s illness narrative.Professionalism, interpreted as patient-centred leadership, gives a direction for medical education that may help doctors to cope with their work

Stretching the Comfort Zone: Using Early Clinical Contact to Influence Professional Identity Formation in Medical Students

Purpose: To explore first-year medical students’ affective reactions to intimate encounters with severely sick patients in their homes, within a curricular innovation targeting the development of a patient-centered professional identity. Background: Early patient encounters create complex emotional challenges and constitute fertile ground for professional identity formation. The literature indicates that students often learn, largely through the hidden curriculum, to avoid and suppress emotion. This can culminate in mental health problems and loss of empathy. Method: A qualitative descriptive analysis of 28 randomly selected, mandatory, reflective essays focused on a home visit to a previously unknown patient, in an unsupervised group of 4 students, within the context of a structured course called Patient Contact—PASKON. Results: Students described a wide range of affect-laden responses, positive and negative, elicited by the home visits. The observations were typically related to loss of control, struggles to behave “professionally,” and the unmasking of stereotypes and prejudices. Conclusions: Medical students’ initial clinical encounters elicit emotional responses that have the potential to serve as triggers for the development of emotional maturity, relational skills, and patient-centered attitudes. Conversely, they can foreground uncertainty and lead to defensive distancing from patients’ existential concerns. The findings point to a role for structured educational strategies and supervision to assist students in the emotion work necessary in the transition from a “lay” to a “medical” identity.publishedVersio

Medisinsk profesjonalitet: Mestring av legeyrket

When the doctor uses theoretical knowledge, clinical skills, and clinical communication in a way that takes care of the patient, this may be called professionalism. The article aims to show that medical professionalism, in all specialities, may be understood and taught through the two complex concepts “leadership” and “patient-centred medicine”. The article is built on a literature-search with a selection of articles based on the authors’ experience in the field. Leadership is an implicit part of clinical work. The concept gives a perspective on the solution of clinical problems and gives a frame for understanding interaction in consultations and in other professional relations. The doctor personal leadership actualizes professional tutoring as part of the education. Models for patient-centred medicine have emphasized the doctor’s attitudes, skills, and use of linguistic means, and they have deepened the doctor’s understanding for exploring the patient’s problem. Newer models also discuss the doctor’s actions and therapeutic actions and underscorethe leader-role in series of decision-making moments in the consultation. Patient-centred clinical work should be based on an understanding of the doctor as an active co-editor and co-producer of the patient’s illness narrative. Professionalism, interpreted as patient-centred leadership, gives a direction for medical education that may help doctors to cope with their work.publishedVersio

The liminal landscape of mentoring - Stories of physicians becoming mentors

Introduction: This study explores narratives of physicians negotiating liminality while becoming and being mentors for medical students. Liminality is the unstable phase of a learning trajectory in which one leaves behind one understanding but has yet to reach a new insight or position. Methods: In this study, we analysed semi-structural interviews of 22 physician mentors from group-based mentoring programmes at two Norwegian and one Canadian medical school. In a dialogical narrative analysis, we applied liminality as a sensitising lens, focusing on informants' stories of becoming a mentor. Results: Liminality is an unavoidable aspect of developing as a mentor. Which strategies mentors resort to when facing liminality are influenced by their narrative coherence. Some mentors thrive in liminality, enjoying the possibility of learning and developing as mentors. Others deem mentoring and the medical humanities peripheral to medicine and thus struggle with integrating mentor and physician identities.They may contradict themselves as they shift between their multiple identities,resulting in rejection of the learning potentials that liminality affords. Conclusion: Mentors with integrated physician and mentor identities can embrace liminality and develop as mentors. Those mentors with contradicting dialogues between their identities may avoid liminality if it challenges their understanding of who they are and make them experience discomfort, confusion and insufficiency while becoming a mentor. Support of the mentoring role from the clinical culture may help these physicians develop internal dialogues that reconcile their clinician and mentor identities

Group mentorship for undergraduate medical students—a systematic review

Introduction - Mentoring has become a prevalent educational strategy in medical education, with various aims. Published reviews of mentoring report very little on group-based mentorship programs. The aim of this systematic review was to identify group-based mentorship programs for undergraduate medical students and describe their aims, structures, contents and program evaluations. Based on the findings of this review, the authors provide recommendations for the organization and assessment of such programs. Methods - A systematic review was conducted, according to PRISMA guidelines, and using the databases Ovid MEDLINE, EMBASE, PsycINFO and ERIC up to July 2019. Eight hundred abstracts were retrieved and 20 studies included. Quality assessment of the quantitative studies was done using the Medical Education Research Study Quality Instrument (MERSQI). Results - The 20 included studies describe 17 different group mentorship programs for undergraduate medical students in seven countries. The programs were differently structured and used a variety of methods to achieve aims related to professional development and evaluation approaches. Most of the studies used a single-group cross-sectional design conducted at a single institution. Despite the modest quality, the evaluation data are remarkably supportive of mentoring medical students in groups. Discussion - Group mentoring holds great potential for undergraduate medical education. However, the scientific literature on this genre is sparse. The findings indicate that group mentorship programs benefit from being longitudinal and mandatory. Ideally, they should provide opportunities throughout undergraduate medical education for regular meetings where discussions and personal reflection occur in a supportive environment

Factors influencing mentors’ satisfaction: A study from medical schools in Norway and Canada

Phenomenon: The mentoring of undergraduate medical students has been shown to benefit the mentors; however, detailed information on the factors that influence the satisfaction and motivation of mentors remains unclear. Such knowledge can be useful in sustaining group mentorship programs. The aim of this study was to investigate the experiences and perspectives of mentors to ascertain the factors that contribute to satisfaction and motivation. Approach: As part of a larger research project, a survey was sent out to mentors at UiT the Arctic University of Norway, the University of Bergen and McGill University (N=461). Descriptive statistics, linear regression and factor analyses were used to examine the data in order to map factors associated with mentor satisfaction. Findings: The overall response rate was 59% (n=272/461). Mentors reported a high mean satisfaction score of 4.55 (±0.04, median 5.00) on a five-point Likert scale. Six out of nine statements describing how mentors approach group mentoring were strongly correlated with each other. Through factor analysis of the items, we found a dominating factor labeled “Student-centered mentoring approach” which was strongly associated with the level of satisfaction as a mentor. Additionally, highly satisfied mentors took a greater interest in patient-centered medicine and their students’ personal development. Their groups spent more time discussing students’ clinical experiences, societal poverty and health, and patients’ suffering and sickness. Insights: Our findings suggest that high mentor satisfaction, which is important for the pedagogical quality and sustainability of mentor programs, is related to the mentors’ student-centeredness and their interest in topics concerning professionalism. By preparing mentors for their roles and supporting them in developing strategies for establishing good mentoring relationships, the outcomes of group mentoring may be improved both for mentors and students. Interest in students’ personal development and the mentors’ own professional development seem to be indicators of mentors’ satisfaction and should be encouraged in mentorship programs