Why impaired wellness may be inevitable in medicine, and why that may not be a bad thing

Context: A wellness crisis exists among physicians and medical trainees. High rates of burnout, depression, stress and other states of impaired wellness have driven a sense of urgency to create solutions, and the medical education community has mobilised impressively. However, we argue—and data suggest—that this rush to find solutions has outpaced our efforts to more fully understand the nature of impaired wellness in medicine. This, we believe, has led to the implementation of solutions informed by limited understanding of the problems we intend to solve. Methods: In this paper, we explore three contributors to this situation: (i) shaky definitions and conceptualisations of wellness, (ii) the predominance of deductive, quantitative research informing our understanding and current solutions, and (iii) the reliance on a ‘disease-focused’ approach to addressing impaired wellness in physicians and trainees. We discuss how these contributors have led to the current state of the science of wellness in medicine: one characterised by an expanding array of solutions built upon narrow conceptualisations of wellness and how it can be impaired. Discussion: Moving beyond the current state of the science on wellness in medicine will require three critical developments: (i) consistent use of clear definitions of wellness; (ii) expanding our methodologies to include those utilising direct interaction with participants; and (iii) moving beyond solutions informed by a disease-model approach. We propose a different way of thinking about wellness: one based on what we view as an inherent—and potentially unavoidable—risk of experiencing impairment during a career in medicine. We argue that efforts to extinguish and eliminate all states of impaired wellness may also eliminate opportunities to develop constructive coping mechanisms and future resilience, and that wellness may best be conceptualised as healthy and authentic engagement with the inevitable adversity of a career in medicine

The potential of narrative analysis for HPE research: Highlighting five analytic lenses

Context Health professions education (HPE) has increasingly turned to qualitative methodology to address a number of the field's difficult research problems. While several different methodologies have been widely accepted and used in HPE research (e.g., Grounded Theory), others remain largely unknown. In this methodology paper, we discuss the value of narrative analysis (NA) as a set of analytic approaches that offer several lenses that can support HPE scholars' research. Methods After briefly discussing the 'narrative turn' in research, we highlight five NA lenses: holistic, situated, linguistic, agentive and sequential. We explore what each lens can offer HPE scholars-highlighting certain aspects of the data-and how each lens is limited-obscuring other aspects. To support these observations, we offer an example of each lens from contemporary HPE scholarship. The manuscript also describes methods that can be employed in NA research and offers two different typologies of NA methods that can be used to access these lenses. Conclusions We conclude with a discussion of how different analytic methods can be used to harness each of the lenses. We urge the deliberate selection and use of NA methods and point to the inherent partiality of any NA approach. Reflecting on our position as narrative scholars, we acknowledge how our own lenses illuminate some areas and conceal others as we tell the story of NA. In conclusion, we invite other researchers to benefit from the potential NA promises

Global Impact of Local Educational Innovation

The innovation is carried out according to the demands or needs of an industrial, social or economic sector and is aimed at the widest possible target audience. In teaching educational innovation, the demand for innovation is very local, it is generated in each subject and for the students of it. This causes that educational innovation cannot be easily transferred between subjects. But, to meet the demands of an educational sector, the target audience for which innovation is designed must be global. The objective of this work is to study whether teaching educational innovation can be considered globally (for a global target audience and for a need in the education sector), so that it can be applied and transferred between subjects from different contexts. The information provided, during 8 training courses, by 130 university professors belonging to 12 different universities has been analyzed. It has been shown that for a given need for improvement (passive habit in students), the profile of the target audience, the demand of the learning sector and the indicators to measure educational innovation can be raised in a common way for an entire educational sector; in this case, higher education. The conclusion is that educational innovation can be designed globally, applied locally and transferred to other contexts

"It's making contacts" : notions of social capital and implications for widening access to medical education

Acknowledgements Our thanks to the Medical Schools Council (MSC) of the UK for funding Study A; REACH Scotland for funding Study B; and Queen Mary University of London, and to the medical school applicants and students who gave their time to be interviewed. Our thanks also to Dr Sean Zhou and Dr Sally Curtis, and Manjul Medhi, for their help with data collection for studies A and B respectively. Our thanks also to Dr Lara Varpio, Uniformed Services University of the USA, for her advice and guidance on collating data sets and her comments on the draft manuscript.Peer reviewedPublisher PD

'I'm sorry to hear that'-Empathy and Empathic Dissonance : the Perspectives of PA Students

Context: Our understanding of clinical empathy could be enhanced through qualitative research-research currently under-represented in the field. Physician associates within the UK undergo an intensive 2-year postgraduate medical education. As a new group of health professionals, they represent a fresh pair of eyes through which to examine clinical empathy, its nature and teaching. Methods: Working with a constructivist paradigm, utilising grounded theory methodology, researchers studied 19 purposively sampled physician associate students in two UK medical schools. One-to-one semi-structured interviews were transcribed verbatim. Data were analysed using a grounded theory approach. Results: The global themes were the pathways to empathy, empathy modifiers and empathic dissonance a novel term to describe the discomfort students experience when pressurised into making empathic statements they don't sincerely feel. Students preferred using non-verbal over verbal expressions of empathy. A conceptual model is proposed. The more substantial empathic pathway, affective empathy, involves input from the heart. An alternative empathy, more constrained, comes from the head: cognitive empathy was considered a solution to time pressure and emotional burden. Formal teaching establishes empathic dissonance, a problem which stems from over-reliance on the empathic statement as the means to deliver clinical empathy. Conclusions: This study furthers our understanding of the construct and teaching of empathy. It identifies empathic barriers, especially time pressure. It proposes a novel concept-empathic dissonance-a concept that challenges medical educationalists to reframe future empathy teaching

Nurse practitioner interactions in acute and long-term care : an exploration of the role of knotworking in supporting interprofessional collaboration

BACKGROUND: Interprofessional care ensures high quality healthcare. Effective interprofessional collaboration is required to enable interprofessional care, although within the acute care hospital setting interprofessional collaboration is considered suboptimal. The integration of nurse practitioner roles into the acute and long-term care settings is influencing enhanced care. What remains unknown is how the nurse practitioner role enacts interprofessional collaboration or enables interprofessional care to promote high quality care. The study aim was to understand how nurse practitioners employed in acute and long-term care settings enable interprofessional collaboration and care. METHOD: Nurse practitioner interactions with other healthcare professionals were observed throughout the work day. These interactions were explored within the context of "knotworking" to create an understanding of their social practices and processes supporting interprofessional collaboration. Healthcare professionals who worked with nurse practitioners were invited to share their perceptions of valued role attributes and impacts. RESULTS: Twenty-four nurse practitioners employed at six hospitals participated. 384 hours of observation provided 1,284 observed interactions for analysis. Two types of observed interactions are comparable to knotworking. Rapid interactions resemble the traditional knotworking described in earlier studies, while brief interactions are a new form of knotworking with enhanced qualities that more consistently result in interprofessional care. Nurse practitioners were the most common initiators of brief interactions. CONCLUSIONS: Brief interactions reveal new qualities of knotworking with more consistent interprofessional care results. A general process used by nurse practitioners, where they practice a combination of both traditional (rapid) knotworking and brief knotworking to enable interprofessional care within acute and long-term care settings, is revealed

The wicked problem of healthcare student attrition

The early withdrawal of students from healthcare education programmes, particularly nursing, is an international concern and, despite considerable investment, retention rates have remained stagnant. Here, a regional study of healthcare student retention is used as an example to frame the challenge of student attrition using a concept from policy development, wicked problem theory. This approach allows the consideration of student attrition as a complex problem derived from the interactions of many interrelated factors, avoiding the pitfalls of small‐scale interventions and over‐simplistic assumptions of cause and effect. A conceptual framework is proposed to provide an approach to developing actions to reduce recurrent investment in interventions that have previously proved ineffective at large scale. We discuss how improvements could be achieved through integrated stakeholder involvement and acceptance of the wicked nature of attrition as a complex and ongoing problem