Medical decisions in 372 hospital encounters

Decision-making is a key activity in health care and clinical decisions are important outcomes of patient-physician encounters. We wanted to study how the dialogue between physician and patient influences decisions about diagnostic procedures and treatment in hospital encounters with patients. Previous studies describing the nature and frequencies of clinical decisions in patient-physician encounters have focused on the degree of patient involvement in the decision-making process. We realized such an approach to clinical decisions might exclude other clinically relevant decisions that are made in medical encounters. Because of this we aimed to describe clinically relevant decisions as they emerge in patient-physician dialogue in a precise, detailed and comprehensive manner. We conducted a qualitative study based on 380 patient-physician encounters from 17 different specialties videotaped at Akershus University Hospital in 2007-2008. Through a content-driven, iterative process involving the perspectives of four physicians we found that clinically relevant decisions in medical encounters comprise more than what has previously been framed as decisions, which called for a broader definition and classification of the term. We have developed a taxonomy consisting of ten topical categories and three temporal categories allowing identification and classification by defining a clinically relevant decision as “a verbal statement committing to a particular course of clinically relevant action and/or statement concerning the patient’s health that carries meaning and weight because it is said by a medical expert”. The taxonomy is named The Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM). Applying DICTUM to our material led us to find an average of 13 clinically relevant decisions in 372 hospital encounters. Content coding of our material has provided a description of clinically relevant decisions across different clinical specialties, settings, physicians and encounters. We think that DICTUM could prove helpful in other descriptive studies of clinical decision-making and aid future studies aiming to assess the quality of medical decisions with regards to level of patient involvement, patient safety, provider professionalism and degree of concordance with evidence based practice

Recall and Understanding of Discharge Information in Observation Ward Patients: An Explorative Observational Study

Effective communication is essential for understanding and recall of hospital discharge information. This study aimed to explore discharge information, patient recall and patient involvement in discharge encounters. We conducted an explorative observational study at a secondary care level, observational ward. Patients discharged to their home were asked to participate. 34 patients were assessed for eligibility, of which 13 were included in the analysis. Multiple sources of data were collected: videotapes of discharge encounters, questionnaires to patients and physicians, and semi-structured interviews with patients 2 weeks after discharge. All patients were satisfied with the information received. Five of the eight patients discharged with more than one change in medication had only partial or no recall of these changes. In seven of the 13 encounters the patients and physicians did not agree on the main message most important information item. The patients were to a small extent involved in decision-making. Our findings highlight the gaps in the information exchange at discharge encounters and the resulting poor information recall among patients. Patients do not seem aware of these gaps. Greater provider awareness of patient involvement in the encounter and inclusion of the patient’s perspective may improve communication, and consequently understanding and recall. Keywords: patient recall, patient perspective, shared decision-making, information exchange, discharg

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

How physicians manage medical uncertainty: A qualitative study and conceptual taxonomy

Background - Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. Objectives - To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians’ tolerance of medical uncertainty. Design - Qualitative study using individual in-depth interviews. Participants - Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1–3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine–pediatrics), at a single large US teaching hospital. Measurements - Semistructured interviews explored participants’ strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. Results - Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. Conclusions - Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work

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

Leger utdannet i Bodø – hvem er de og hvor blir de av?

BAKGRUNN Siden 2009 har inntil 24 legestudenter ved Universitetet i Tromsø årlig fullført de to siste årene av utdanningen i Bodø (kalt Bodøpakken). Vi kartla oppvekstkommune, ønsker for framtidig spesialitet blant studentene og hvor og hva studentene arbeidet med etter LIS1-tjenesten. MATERIALE OG METODE Legestudenter uteksaminert i Bodø i perioden 2012–18 fikk et spørreskjema første uke av sjette studieår med spørsmål om blant annet oppvekststed og ønsker for framtidig arbeidssted og spesialitet. Vi kartla arbeidssted og spesialitet for disse per januar 2021 samt for de to kullene som ble uteksaminert i 2010–11. Sistnevntes oppvekststed ble kartlagt ved hjelp av direkte kontakt, kullkontakter eller åpne internettkilder. Samvariasjon mellom oppvekststed og arbeidssted, spesialitetsønske og spesialitetsvalg ble analysert ved khikvadrattest og logistisk regresjon. RESULTATER Blant de 146 legene som har fullført Bodøpakken og LIS1-tjenesten, hvorav 91 (62,3 %) var kvinner, var Bodø oppvekstkommune og arbeidssted for henholdsvis 40 (27,4 %) og 56 (38,4 %). For øvrige Nordland var tilsvarende tall 54 (37,0 %) og 38 (26,0 %), for Troms og Finnmark 23 (15,8 %) og 19 (13 %) og for øvrige Norge 29 (19,9 %) og 33 (22,6 %). 51 (34,9 %) arbeidet som allmennleger, hvorav 34 (66,7 %) i distriktskommuner. Det var større sannsynlighet for at man arbeidet i distriktet dersom man var vokst opp i slike strøk (oddsratio (OR) 3,0 (95 % KI 1,5 til 6,1)), og at man arbeidet i allmennmedisin dersom man som ønsket dette som student (OR 3,7 (95 % KI 1,8 til 7,6)). FORTOLKNING Bodøpakken har i stor grad tiltrukket seg studenter med tilhørighet til regionen. En stor andel av studentene som tok en del av utdanningen i Bodø jobbet på Nordlandssykehuset Bodø og i allmennmedisin, især i distriktskommuner, ved undersøkelsestidspunktet

LIS1-leger og medisinsk usikkerhet – en kvalitativ studie

BAKGRUNN - Hvordan norske leger håndterer medisinsk usikkerhet, er lite studert. Formålet med studien var å undersøke hvordan leger i spesialisering del 1 (LIS1-leger) opplever og håndterer usikkerhet i en klinisk hverdag. MATERIALE OG METODER - Ti LIS1-leger ved to sykehus ble rekruttert til intervjuer etter svarmønsteranalyse fra et kartleggende spørreskjema. Intervjuene ble analysert med systematisk tekstkondensering. RESULTATER - Analysen avdekket tre hovedtemaer i intervjuene: håndtering av medisinsk usikkerhet, personlig respons på medisinsk usikkerhet samt arbeidsmiljø, tilbakemeldinger og forberedelse. Innen alle de tre tematiske områdene brukte informantene ordene sikker/usikker og trygg/utrygg om hverandre. FORTOLKNING - LIS1-legene strevde med medisinens iboende usikkerhet og kjente på en betydelig utrygghet, spesielt i starten av tjenesten. Mottakelsen og tilbakemeldingene legene fikk på arbeidsplassen var viktige. Den medisinske utdannelsen hadde i liten grad forberedt LIS1-legene på møtet med medisinsk usikkerhet i en klinisk hverdag

Investigating Morphological Decomposition of Established and Novel Compound Nouns in L1 English Speakers and Norwegian L2 English Speakers - A masked Lexical Decision Task study

Abstract Through a masked Lexical Decision Task experiment, the current thesis finds evidence for a sublexical morphological decomposition of established orthographically contiguous compound nouns (such as |toothbrush|) in Norwegian L2 English speakers, but not in native English speakers. Furthermore, this difference between the subject groups is not present with novel orthographically contiguous compound nouns (such as|groundlord|), where both subject groups showed sublexical morphological decomposition. The data indicates that Norwegian L2 English speakers morphologically decompose as their first mechanism - while native English speakers employ a whole word look-up as their first mechanism in visual word recognition and lexical access of compound nouns. It is suggested this distinction is rooted in the differing productive and orthographic norms Norwegian and English portray in compound nouns, and that Norwegian L2 English speakers carry over their L1 decompositional behaviors to their L2 processing