No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Temporary Matters
Abstract
Medical students and resident physicians spend much of their training engaged in transient, time-limited relationships with patients, families, and other care providers. This article offers a partial catalog of the problems that the evanescent nature of trainees' relationships with others creates in their lives, the strategies they often use to address these problems, and the deleterious consequences these strategies may have on their behavior and ethical development.
... 56 Trainees support the mission of institutions by supporting and even leading initiatives. 57 However, trainees may often be viewed as transient within the organization, 58 as it is common to leave for further training or jobs in other organizations after program completion. 59 As such, trainees often have wide variation in benefits they receive across organizations 60 and may receive less prioritization for organizational investment. ...
Purpose
Psychological safety is critical for fostering well-being. Integral to the mission of academic institutions, trainees are among the most vulnerable to negative workplace experiences, calling for a need to understand factors that contribute to psychological safety in this population. Our objective is to empirically explore trainee psychological safety to inform best practices for training environments.
Design
A survey was used to capture organizational, interpersonal, and individual factors, as well as demographic information in graduate, postdoctoral, medical, resident, and fellow trainees. Descriptive statistics, multivariate ordinal logistic regression, and dominance analyses were used to understand psychological safety and the predictors that explained the majority of the variance in its statistical model.
Findings
Gender minorities and those who suppressed their race information were less likely to feel psychologically safe. Psychological safety was predominately explained by senses of belonging, recognition, and respect. Notably, trust and confidence in supervisor emerged as a pivotal factor influencing belonging and respect, whereas organizational support played a crucial role in fostering recognition and belonging. Intriguingly, clarity in role expectations and autonomy were positively correlated with recognition.
Originality
Our findings highlight the interplay between organizational, interpersonal, and individual dynamics shaping psychological safety. Importantly, those who suppress their race as well as female or gender minorities are disproportionally prone to feeling unsafe. We further elucidate role clarity and autonomy as important factors in achieving a sense of recognition. We suggest programs prioritize development beyond technical competencies, recognizing trainees as key stakeholders in the cultivation of positive culture within academic environments.
... Ideally, longitudinal relationships with patients and teachers also prevent the erosion of students' values [32]. In such longitudinal relational models, students have meaningful roles on an inter-professional care team over time preventing the risk of objectification of others [43] that comes with transient social relationships [44]. Indeed, the success of the model is predicated on the integrity and strength of the learner-patient, learner-teacher, and learner-community relationships over time. ...
Health systems worldwide are increasingly unable to meet individual and population health needs. The shortage of healthcare workers in rural and other underserved communities is compounded by inadequate primary care infrastructure and maldistribution of services. At the same time, the medical education system has not changed to address the growing mismatch between population health needs and care delivery capacity. Internationally, leaders are calling for change to address these challenges. Substantive changes are needed in medical education’s stance, structure, and curricula. Educational continuity and symbiosis are two guiding principles at the center of current clinical educational redesign discourse. These principles rely on empirically-derived science to guide educational structure and improve outcomes. Educational continuity and symbiosis may improve student learning and support population health through workforce transformation. Longitudinal integrated clerkships (LICs), growing out of workforce imperatives in the 1970s, have demonstrated sustainable educational and workforce outcomes. Alongside the success of LICs, more innovation and more reaching innovation are needed. We propose restructuring clinical medical education specifically to address workforce needs and develop science-minded (rigorous, inquisitive, and innovative) and service-minded (humanistic, community-engaged, and socially accountable) graduates.
... Thus, it is not enough simply to replace the curative model of medicine with the palliative model because we may unwittingly reentrench some of the values found implicitly in the curative model of medicine. For example, Dimitri A. Christakis and Chris Feudtner (1997) have argued that, within the curative model, ''the hierarchy of rank [often] determines to what degree other staff members can question a certain decision and course of therapeutic action'' (740). We could easily envision a palliative ontological approach that nevertheless viewed the physician's recommendation, given her position in the hierarchy, as immune from the critique of other members of staff or from her patient's concerns. ...
In this article, I address the role of hope in medical decision making. Against the backdrop of the so-called paradox of hope, I consider the relationship between medical futility and the preservation of hope. I build on the work of feminist bioethicists to argue that only a feminist approach to palliation may properly dissolve the paradox of hope.
Purpose:
Ethical erosion literature describes medical students' patient centredness and empathy declines through their clinical years of training. Longitudinal Integrated Clerkships (LICs), an alternate clinical educational design, have been hypothesised to reduce ethical erosion. The authors aimed to measure change in medical students' patient centredness and empathy at an institution with the largest LIC worldwide.
Method:
Two whole LIC cohorts (LIC1 and LIC2) were invited to complete a questionnaire, which included patient centredness and empathy scales. Students completed the questionnaire at the start and end of each academic year. Block-rotation students (Non-LIC) were a comparator cohort. Complete cases data were analysed.
Results:
22 Non-LIC, 66 LIC1 and 33 LIC2 students responded. Non-LIC students experienced a significant decline in empathy ([start] 113.14 vs. [end] 102.68, p<.001). Empathy did not significantly decline in the LIC cohorts. Patient centredness in LIC1 and LIC2 grew and reduced in the Non-LIC cohort, however, these changes were not statistically significant.
Conclusions:
This study supports the hypothesis LICs may reduce ethical erosion when compared to block-rotation placements. The results provide evidence that ethical erosion occurs in students who have completed block-rotation placements. This is the first study of UK-based medical students measuring empathy and patient centredness following completion of an LIC.
Background
Strong relationships between trainees and physician supervisors can positively influence how trainees navigate workplace learning. How trainees act and learn in clinical workplaces characterized by rapidly developing and dissolving supervisory pairings is less well understood. This study uses the emergency department (ED) to examine the impact of transient supervisory relationships on how residents approach clinical learning opportunities.
Methods
We retrospectively analyzed pediatric and emergency medicine resident rotations in an urban, tertiary, academic pediatric ED between July 2018 and June 2022. Using social network analysis (SNA), we identified resident–attending dyads and patients seen by each dyad. This informed semistructured interviews to understand how transience in supervisory relationships influences how residents approach and interpret clinical experiences. With self‐determination theory as an organizing framework, the investigators performed line‐by‐line coding with constant comparative analysis which supported subsequent theoretical coding.
Results
During the study, 526 residents completed 1013 rotations with 87 attendings. A mean (±SD) of 25 (±7) attendings supervised a resident per rotation, with dyads caring for a mean (±SD) of 4 (±4) patients. Twelve residents were interviewed and described different paths to learning depending on the transience of their relationships with clinical supervisors. More sustained contact presented an opportunity to build competence by fostering autonomy and feedback, while briefer contact advanced residents’ competence by exposing them to variable practice patterns.
Conclusions
Combining SNA with qualitative analysis revealed that residents in the ED experience a spectrum of contact with attendings and perceive different paths to learning depending on the transience of this relationship. The results suggest different educational strategies may be necessary to maximize learning depending on the length or resident–attending interactions.
Longitudinal Integrated Clerkships (LICs) prioritise longitudinal relationships with faculty, patients, and place. Research shows that LICs benefit students and faculty, but most medical schools have limited LIC programmes. This is likely due to perceptions that LICs are more costly and complex than traditional block rotations (TBRs). The perceived cost versus evidence-based value related to clerkship education has not been examined in detail. Until recently, no 'All-LIC' medical school exemplars existed in the US, limiting the value of this model as well as the ability to examine relative cost and complexity. In this paper, we draw on our experience launching three 'All-LIC' medical schools in the United States - schools in which the entire clerkship class participates in a comprehensive clerkship-year LIC. We propose that the known benefits of LICs coupled with cost-mitigation strategies related to running an 'All LIC' model for core clinical clerkships, rather than block and LIC models simultaneously, results in a higher value for medical schools.
The problem:
Medical schools require highly skilled and committed clinical faculty to teach, assess, supervise and mentor students' clinical care. Medical education is facing a crisis in recruiting and sustaining these clinical teachers. Faced with multiple demands and responsibilities in fast-paced clinical environments, teachers may not have the time, resources or stamina to sustain these critical roles. Medical school leaders must commit to and provide structures and processes to attract, sustain and retain clinical teachers.
Conceptual framework:
The authors use the lens of self-determination theory to frame approaches to support teacher sustainability. Self-determination theory describes sources of human motivation. The theory and its evidence base characterise three human psychological needs: autonomy, competence, and relatedness. This theory can bridge individual psychological and institutional leadership perspectives to help medical school leaders anticipate and respond to their clinical teachers' needs. The authors propose three practical steps: practices to advance employee-centredness, processes to align individual and institutional values, and restructuring education to support clinical teachers' needs alongside student and patient needs. The authors describe limitations to this relational approach that focuses on leadership actions and consider individual agency as another key factor for sustainability.
Discussion:
Medical school leaders can develop and apply theory-driven approaches to advance sustainability. Sustainability now and in the future requires careful attention to the needs of clinical teachers and to their relationships with and within medical schools.
Problem: Student mistreatment represents an ongoing challenge for US medical schools. Students experiencing mistreatment may become marginalized and cynical, and they have higher rates of burnout, depression and substance use disorders. Although numerous attempts to eliminate mistreatment have been proposed, best practices remain elusive. We formed a unique student-faculty collaboration (the Ending Mistreatment Task Force) that allowed all voices to be heard and enabled identification of five interventions to reduce mistreatment.
Intervention: The EMTF developed and implemented five key interventions: 1) a shared mistreatment definition; 2) measures to increase faculty accountability, including adding professionalism expectations to faculty members’ contracts and performance reviews; 3) a Professionalism Office to respond promptly to students’ reports of mistreatment and provide feedback to faculty; 4) tools to help teachers provide authentic learning environments for students, while addressing generational misunderstandings; and 5) student-produced videos, helping faculty understand the impact of mistreatment as seen through students’ eyes.
Context: These interventions occurred at one medical school where mistreatment reports were consistently above national averages.
Impact: Over 6 years, the interventions helped reduce the rate of student-reported mistreatment by 36% compared with a 4% decline across all US medical schools.
Lessons: The collaborations between students and faculty helped each party identify unexpected misunderstandings and challenges. We learned that students want hard questions, although faculty are often afraid to challenge students for fear of offending them or being reported. We clarified differences between mistreatment and sub-optimal learning environments and openly discussed the pervasive opinion that ‘some’ mistreatment is important for learning. We also identified ongoing challenges, including the need to solicit residents’ perspectives regarding mistreatment and develop proper responses to disrespectful comments directed at patients, family and colleagues. The collaboration reinforced students’ and faculty members’ shared commitment to upholding a respectful learning and clinical care environment and ending mistreatment.
Purpose:
To determine the effect of patient debrief interviews on pediatric clerkship student depth of reflection and learning.
Method:
The authors conducted a multi-institutional, mixed-methods, cluster randomized trial among pediatric clerkship students from July 2016 to February 2017. Intervention students completed a debrief interview with a patient-caregiver, followed by a written reflection on the experience. Control students completed a written reflection on a memorable patient encounter. Three blinded authors scored written reflections according to the 4-level REFLECT rubric to determine depth of reflection. Inter-rater reliability was examined using kappa. REFLECT scores were analyzed using a chi-squared test; essays were analyzed using content analysis.
Results:
Eighty percent of eligible students participated. One hundred eighty-nine essays (89 control, 100 intervention) were scored. Thirty-seven percent of the control group attained reflection and critical reflection, the two highest levels of reflection, compared to 71% in the intervention group; 2% of the control group attained critical reflection, the highest level, compared to 31% in the intervention group (χ(3, N=189) = 33.9, P < .001). Seven themes were seen across both groups, three focused on physician practice and four focused on patients. Patient-centered themes were more common in the intervention group whereas physician-focused themes were more common in the control group.
Conclusions:
Patient debrief interviews offer a unique approach to deepen self-reflection through direct dialogue and exploration of patient-caregiver experiences during hospitalization.
Background: Traditional preclinical curricula based on memorization of scientific facts constitute learning environments which may negatively influence both factual understanding and professional identity development in medical students. Little is known of how students themselves experience and interpret such educational milieus.Objective: To investigate first-year medical students’ view of the physician role, and their perception of the relevance and quality of teaching in a science-based preclinical curriculum.
Design: Focus group interviews with thematic text analysis.
Results: Students portrayed the good physician as communicative, humble, and open, combining biomedical knowledge and moral strength. When asked how medical school supported the development of such characteristics, two partly contradictory discourses emerged. The critical discourse identified decontextualized knowledge, poor pedagogy, lack of critical thinking, and contact with faculty. Students who voiced critical comments also articulated trust that the system would provide the competence they needed, that basic biological knowledge is needed before clinical practice, and that being on your own conveys freedom and responsibility, and helps you grow up.
Conclusion: Trust in the educational system, within a substandard learning environment, created cognitive dissonance that students resolved through rationalization, whereby they negated that factual overload and lack of relevance, reflection, and personal feedback was problematic. The cost of this mechanism is possibly that inferior teaching is perceived as normal, necessary, and good enough. If so, these future physicians’ ability to critically evaluate and create quality in medical education and practice, may be weakened.
Objective
To evaluate the medical student perception of unprofessional experiences on the obstetrics and gynecology clerkship through evaluation of reflective essays using qualitative research and grounded theory.
Methods
All third year medical students rotating through OBGYN were required to write an essay on an experience they had with positive and/or negative professionalism during their clinical rotation. Essays were analyzed from a total of 220 students and coded into eight domains with subcategories. Inter-rater reliability was established with two of the coders (MR and BG) with high levels of correlation kappa’s agreement 0.73 CI (0.57, 0.88). Qualitative analysis using grounded theory was deployed for essay theme analysis. Frequencies were used for descriptive purposes.
Results
Most students chose to write about incidents of negative professionalism that they observed. The most common domain themes were medical team dynamics (19%), inpatient interactions (20%), and inappropriate remarks about a patient (16%). A quarter (26%) of the essays also included an observation of a positive demonstration of professionalism.
Conclusion
Students frequently report experiencing mistreatment through the perception of a hostile learning environment. The essays described frequent exposure to unprofessional actions that can create a hostile learning environment and thus potential mistreatment. The students frequently wrote about witnessing unprofessional comments made by team members about patients, residents, and other students. All medical educators need to work to reduce student mistreatment through reducing unprofessional behavior.
One vital goal of medical education is to promote the development of desirable professional qualities among future physicians, such as compassion, empathy, and humanism. Future physicians must finish their training prepared to meet the changing health needs of society, yet in reality many students graduate from medical school more cynical and less empathetic than when they began. During clinical clerkships, many students experience an "ethical erosion" as they transition in to real world clinical settings. Through innovative longitudinal integrated curricular designs focusing on continuity, medical students participate in the comprehensive care of patients over time and have continuous ongoing learning relationships with the responsible clinicians. As patients place increasing importance on the doctor-patient relationship, learning models that foster stronger connections between medical students and their patients, as well as with their teachers and communities, are needed in order to better prepare the next generation of physicians to serve a changing health care system.
One vital goal of medical education is to promote the development of desirable professional qualities among future physicians, such as compassion, empathy, and humanism. Future physicians must finish their training prepared to meet the changing health needs of society, yet in reality many students graduate from medical school more cynical and less empathetic than when they began. During clinical clerkships, many students experience an "ethical erosion" as they transition in to real world clinical settings. Through innovative longitudinal integrated curricular designs focusing on continuity, medical students participate in the comprehensive care of patients over time and have continuous ongoing learning relationships with the responsible clinicians. As patients place increasing importance on the doctor-patient relationship, learning models that foster stronger connections between medical students and their patients, as well as with their teachers and communities, are needed in order to better prepare the next generation of physicians to serve a changing health care system.
There is increased interest in longitudinal integrated clerkships (LICs) due to mounting evidence of positive outcomes for students, patients and supervising clinicians. Emphasizing continuity as the organizing principle of an LIC, this article reviews evidence and presents perspectives of LIC participants concerning continuity of care, supervision and curriculum, and continuity with peers and systems of care. It also offers advice on implementing or evaluating existing LIC programs.
Objectives:
In this review, we examine features of ICU systems and ICU clinician training that can undermine continuity of communication and longitudinal guidance for decision making for chronically critically ill infants and children. Drawing upon a conceptual model of the dynamic interactions between patients, families, clinicians, and ICU systems, we propose strategies to promote longitudinal decision making and improve communication for infants and children with prolonged ICU stays.
Data sources:
We searched MEDLINE and PubMed from inception to September 2015 for English-language articles relevant to chronic critical illness, particularly of pediatric patients. We also reviewed bibliographies of relevant studies to broaden our search.
Study selection:
Two authors (physicians with experience in pediatric neonatology, critical care, and palliative care) made the final selections.
Data extraction:
We critically reviewed the existing data and models of care to identify strategies for improving ICU care of chronically critically ill children.
Data synthesis:
Utilizing the available data and personal experience, we addressed concerns related to family perspectives, ICU processes, and issues with ICU training that shape longitudinal decision making.
Conclusions:
As the number of chronically critically ill infants and children increases, specific communication and decision-making models targeted at this population could improve the feedback between acute, daily ICU decisions and the patient's overall goals of care. Adaptations to ICU systems of care and ICU clinician training will be essential components of this progress.
The authors argue that Nel Noddings' philosophy, "an ethic of caring," may illuminate how students learn to be caring physicians from their experience of being in a caring, reciprocal relationship with teaching faculty. In her philosophy, Noddings acknowledges two important contextual continuities: duration and space, which the authors speculate exist within longitudinal integrated clerkships. In this Perspective, the authors highlight core features of Noddings' philosophy and explore its applicability to medical education. They apply Noddings' philosophy to a subset of data from a previously published longitudinal case study to explore its "goodness of fit" with the experience of eight students in the 2012 cohort of the Columbia-Bassett longitudinal integrated clerkship. In line with Noddings' philosophy, the authors' supplementary analysis suggests that students (1) recognized caring when they talked about "being known" by teaching faculty who "cared for" and "trusted" them; (2) responded to caring by demonstrating enthusiasm, action, and responsibility toward patients; and (3) acknowledged that duration and space facilitated caring relations with teaching faculty. The authors discuss how Noddings' philosophy provides a useful conceptual framework to apply to medical education design and to future research on caring-oriented clinical training, such as longitudinal integrated clerkships.
Postgraduate medical trainees are not well prepared difficult conversations about goals of care with patients and families in the acute care clinical setting. While contextual nuances within the workplace can impact communication, research to date has largely focused on individual communication skills. Our objective was to explore contextual factors that influence conversations between trainees and patients/families about goals of care in the acute care setting.
We conducted an exploratory qualitative study involving five focus groups with Internal Medicine trainees (n = 20) and a series of interviews with clinical faculty (n = 11) within a single Canadian centre. Thematic framework analysis was applied to categorize the data and identify themes and subthemes.
Challenges and factors enabling goals of care conversations emerged within individual, interpersonal and system dimensions. Challenges included inadequate preparation for these conversations, disconnection between trainees, faculty and patients, policies around documentation, the structure of postgraduate medical education, and resource limitations; these challenges led to missed opportunities, uncertainty and emotional distress. Enabling factors were awareness of the importance of goals of care conversations, support in these discussions, collaboration with colleagues, and educational initiatives enabling skill development; these factors have resulted in learning, appreciation, and an established foundation for future educational initiatives.
Contextual factors impact how postgraduate medical trainees communicate with patients/families about goals of care. Attention to individual, interpersonal and system-related factors will be important in designing educational programs that help trainees develop the capacities needed for challenging conversations.
Though few question the importance of incorporating professionalism and humanism in the training of physicians, traditional residency programs have given little direct attention to the processes by which professional and humanistic values, attitudes, and behaviors are cultivated. The authors discuss the underlying philosophy of their primary care internal medicine residency program, in which the development of professionalism and humanism is an explicit educational goal. They also describe the specific components of the program designed to create a learner-centered environment that supports the acquisition of professional values; these components include a communication-skills training program, challenging-case conferences, home visits with patients, a resident support group, and a mentoring program. The successful ten-year history of the program shows how a residency program can enable its trainees to develop not only the requisite excellent diagnostic and technical tools and skills but also the humane and professional attributes of the fully competent physician.
Objective
This study investigated third-year students’ experience with the emergency medicine (EM) component in integrated longitudinal programs. The study aimed to see if EM could be integrated into third-year integrated longitudinal programs while addressing accreditation standards and increasing interest in EM.
Methods
The authors surveyed students who participated in an integrated longitudinal program at University of California San Francisco School of Medicine (UCSF) from 2010 to 2012. The survey focused on four areas of EM: fit within an integrated longitudinal program; development of critical decision-making and judgment skills; development of differential diagnoses and treatment plans; increased interest in pursuing EM.
Results
Overall, students thought that EM fits well with the goals of an integrated longitudinal curriculum. They also thought that it helped them develop their decision-making, clinical judgment, differential diagnoses, and treatment plans. There was also an increased interest in pursuing EM as a career option because of the EM component.
Conclusions
EM can be well integrated into a third-year longitudinal curriculum. The undifferentiated patient work-up helps students develop critical skills in assessment and management. The lack of continuity did not interfere with the integrated longitudinal curriculum, instead the experience enhanced it.
Purpose:
To examine student perceptions and learning outcomes of three different third-year clerkship models: a yearlong, longitudinal, integrated clerkship (LIC); six-month clerkships with continuity (hybrid); and traditional, discipline-specific block clerkships (BCs).
Method:
The authors compared the perceptions regarding the clerkship year and the hidden curriculum, as well as the pre- and postclerkship academic performance, of third-year medical students participating in LIC, hybrid, and BC models between 2006 and 2010.
Results:
Generally, LIC students rated the following clerkship experiences higher than did the hybrid and BC students: faculty teaching, faculty observation of clinical skills, feedback, and the clerkship overall. Students in the LIC observed more positive role-modeling behaviors and had more patient-centered experiences than BC students. All students preferred to see patients more than once, work within a consistent site or system, and work with a stable group of peers and faculty mentors over time. Whereas students in both the LIC and the hybrid models outperformed their BC counterparts in clinical skills, student performance on the U.S. Medical Licensing Exam Step 2 (clinical knowledge) was equivalent across models.
Conclusions:
Key differences in student experiences and outcomes between the continuity clerkship models (LIC and hybrid) and BCs reinforce the literature and the educational framework for continuity in clinical learning. The benefits to student outcomes seem to increase with greater opportunities for continuity.
Although longitudinal community-based care of patients provides opportunities for teaching patient centredness and chronic disease management, there is a paucity of literature assessing learning outcomes of these clerkships. This study examines learning outcomes among students participating in longitudinal community based follow-up of patients discharged from the hospital.
The authors conducted a thematic analysis of 253 student narratives written by 44 third-year medical students reflecting on their longitudinal interactions with patients with chronic medical illnesses. The narratives were written over three periods: after acute hospital encounter, after a home visit and at the end of the 10-month follow-up. Analysis involved coding of theme content and counting of aggregate themes.
The most frequent theme was 'chronic disease management' (25%) followed by 'patient-centred care' (22%), 'health care systems' (20.9%), 'biomedical issues' (19.7%), 'community services' (9.5%) and 'student's role conflict' (2.3%). There was a shift in the relative frequency of the different themes, as students moved from hospital to community with their patients. Biomedical (44.3%) and health systems (18.2%) were the dominant themes following the acute hospitalization encounter. Chronic disease management (35.1%) and patient centredness (31.8%) were the dominant themes after the 10-month longitudinal follow-up.
Longitudinal community-based interaction with patients resulted in learning about chronic disease management, patient centredness and health care systems over time. Students shifted from learning biomedical knowledge during the acute hospitalization, to focus on better understanding of long-term care and patient centredness, at the end of the module.
Interest in longitudinal integrated clerkships (LICs) as an alternative to traditional block rotations is growing worldwide. Leaders in medical education and those who seek physician workforce development believe that "educational continuity" affords benefits to medical students and benefits for under-resourced settings. The model has been recognized as effective for advancing student learning of science and clinical practice, enhancing the development of students' professional role, and supporting workforce goals such as retaining students for primary care and rural and remote practice. Education leaders have created multiple models of LICs to address these and other educational and health system imperatives. This article compares three successful longitudinal integrated clinical education programs with attention to the case for change, the principles that underpin the educational design, the structure of the models, and outcome data from these educational redesign efforts. By translating principles of the learning sciences into educational redesign efforts, LICs address the call to improve medical student learning and potential and advance the systems in which they will work as doctors.
Oscar Thompson, a third-year medical student on a shift in the emergency department, is eager to participate in as many procedures
as possible. According to the triage nurse’s history, the next patient to be seen is a 58-year-old man who has had fever,
headache, and neck stiffness. Anticipating his first lumbar puncture, Oscar approaches the room with enthusiasm. The nurse
whispers that the patient is irritated and can’t wait to see the doctor. The student pauses, draws back the curtain, and says,
“Hello, I’m Dr. Thompson, how can I help you today?”
The authors report data from the Harvard Medical School-Cambridge Integrated Clerkship (CIC), a model of medical education in which students' entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships.
The authors compared 27 students completing the first three years of the CIC (2004-2007) with 45 students completing clerkships at other Harvard teaching hospitals during the same period. At baseline, no significant between-group differences existed (Medical College Admission Test and Step 1 scores, second-year objective structured clinical examination [OSCE] performance, attitudes toward patient-centered care, and plans for future practice) in any year. The authors compared students' National Board of Medical Examiners Subject and Step 2 Clinical Knowledge scores, OSCE performance, perceptions of the learning environment, and attitudes toward patient-centeredness.
CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness.
CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.
To address challenges to clinical education, clerkships should be designed to promote continuity of educational experiences including continuity in teaching. Yet, little is known about how continuity in teaching impacts clinical teachers. Experiences of clinical teachers who precept students during a longitudinal integrated clerkship (LIC) must be examined.
The authors interviewed 27 preceptors who could compare their LIC with traditional clerkship teaching experiences.
Teaching during an LIC had a significant impact on preceptors' time, effort, and clinic responsibilities. Preceptors felt they bore sole responsibility for teaching a discipline and ensuring students' learning, and they experienced a deep sense of reward observing students' growth.
To support and sustain the reward of LIC teaching for faculty, LIC developers should focus on targeted faculty development and resource allocation to clinical teaching.
Most medical schools value and seek to create opportunities for students to learn through experiences in the longitudinal care of patients. A number of innovative programs have made longitudinal care the central experiential component of principal clinical year education.The authors sought to identify ways in which learning through the longitudinal care of patients in an innovative longitudinal integrated clerkship contributes to the education of students in their principal clinical year.
The authors reviewed 16 narratives written by 14 of the 38 students from the first four years of the Harvard Medical School-Cambridge Integrated Clerkship, 2004-2007, to identify important aspects of learning from longitudinal care.
Students reported that the clerkship structure created a dynamic learning environment that helped them to more broadly learn about their patients' diseases and experiences of illness. Students described feeling deeply connected to "their" patients, which transformed their roles and inspired their reflections. With more thorough knowledge of their patients over time, they felt they made important contributions to their patients' care, not only in providing emotional support but also in bridging gaps in the delivery of services and in motivating deeper exploration into relevant medical and social issues. Students reported that their connections with patients over time inspired a sense of idealism and advocacy.
Organizing learning in the principal clinical year around longitudinal patient care seems to offer significant advantages for learning and professional development.
Most dying patients are treated by physicians in community practice, yet studies of terminal care rarely include these physicians.
To examine the frequency of life-sustaining treatment use and describe what factors influence physicians' treatment decisions in community-based practices.
Family members and treating physicians for decedents 65 years and older who died of cancer, congestive heart failure, chronic lung disease, cirrhosis, or stroke completed interviews about end-of-life care in community settings.
Eighty percent of eligible family and 68.8% of eligible physicians participated (N = 165). Most physicians were trained in primary care and 85.4% were primary care physicians for the decedents. Physicians typically knew the decedent a year or more (68.9%), and 93.3% treated them for at least 1 month before death. In their last month of life, 2.4% of decedents received cardiopulmonary resuscitation, 5.5% received ventilatory support, and 34.1% received hospice care. Family recalled a discussion of treatment options in 78.2% of deaths. Most discussions (72.1%) took place a month or more before death. Place of death, cancer, and having a living will were independent predictors of less aggressive treatment before death. Physicians believed that advanced planning and good relationships were the major determinants of good decision making.
Community physicians use few life-sustaining treatments for dying patients. Treatment decisions are made in the context of long-term primary care relationships, and living wills influence treatment decisions. The choice to remain in community settings with a familiar physician may influence the dying experience.
This study assessed whether greater continuity of care is associated with timely administration of measles-mumps-rubella (MMR) vaccination.
We studied 11,233 patients continuously enrolled in Group Health Cooperative (GHC) from birth to 15 months. We used a preestablished index to quantify continuity of care based on the number of primary care providers in relation to the number of clinic visits. MMR vaccination status at 15 months was assessed with automated immunization data systems at GHC.
In a logistic regression model, both medium continuity (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.08, 1.33) and high continuity (OR = 1.36, 95% CI = 1.22, 1.52) were associated with increased likelihood of being immunized by 15 months compared with patients in the lowest tercile of continuity of care.
Greater continuity of care is associated with more timely immunization.
Community-based education and service learning are becoming increasingly common in health and human services education. As students enter the community, several ethical dilemmas arise regarding the university's interaction with the community. This article explores clinical, agency, and community placements in terms of the relationships they engender between the university and the community. The article then outlines some ethical obligations of universities and faculty members and ethical dilemmas that arise in different placements. Finally, a fundamental ethical framework that may guide universities and faculty members in planning community-based educational experiences is proposed.
Since 1995, the University of California, San Francisco, School of Medicine has monitored students' professional behaviors in their third and fourth years. The authors recognized that several students with professionalism deficiencies during their clerkships had manifested problematic behaviors earlier in medical school. They also observed behaviors of concern--such as inappropriate behavior in small groups--in some first- and second-year students who could have been helped by early remediation. The authors describe the modifications to the evaluation system to bring professionalism issues to a student's attention in a new, earlier, and heightened way. In this new system for first- and second-year students, the course director of a student who has professionalism deficiencies submits a Physicianship Evaluation Form to the associate dean for student affairs, who then meets with the student to identify the problematic issues, to counsel, and to remediate. The student's behavior is monitored throughout the academic years. If the student receives two or more forms during the first two years and a subsequent form in the third or fourth year, this indicates a persistent pattern of inappropriate behavior. Then the physicianship problem is described in the dean's letter of recommendation for residency and the student is placed on academic probation. The student may be eligible for academic dismissal from school even if he or she has passing grades in all courses. The authors describe their experience with this system, discuss lessons learned, and review future plans to expand the system to deal with residents' mistreatment of students.
To examine the influence of education and clinical experience on residents' attitudes toward withdrawal of life support.
Self-administered survey.
Four Canadian teaching hospitals.
Residents rotating through four intensive care units.
The survey examined ethics education and experience regarding end-of-life care, importance of factors influencing withdrawal of life support, confidence in decisions, and recommendations for enhancing end-of-life education. The response rate was 83.9% (52 of 62). A minority of residents reported an appropriate amount of formal teaching on ethical principles (17.3%), patient-centered education (28.8%), and informal discussion (28.8%) before their intensive care unit rotation. During their rotation, most residents cared for patients in whom withdrawal of life support was considered. Although they usually attended family meetings, residents were never (34.6%) or rarely (42.3%) the primary discussant. Before the intensive care unit rotation, confidence in withdrawal decisions was related to male sex (p =.001) and previous patient-centered ethics education (p =.02). At the end of the intensive care unit rotation, only resident involvement in family meetings (p =.02) and being the primary discussant at such meetings (p =.01) were associated with confidence. After we adjusted for pre-rotation confidence in withdrawal of life support decision-making, the only predictor of post-rotation confidence was family meeting involvement (p <.001). Residents recommended more patient-centered discussion, observation of attending physicians discussing end-of-life issues, and opportunity to lead family meetings.
Experiential, case-based, patient-centered curricula are associated with resident confidence in withdrawal of life support decisions in the intensive care unit.
To assess day-to-day emotions and the experiences that trigger these emotions for medical trainees in hospital settings. The overarching goal was to illuminate training experiences that affect professional behaviors of physicians.
This qualitative study, conducted April-June 2000, used semistructured, open-ended interviews, observations by a non-participant, and a self-report task at two inpatient services (internal medicine and pediatrics) at different hospitals within a single academic institution in the northwestern United States. Twelve team members, including medical students, interns, residents, and attendings, were invited to participate. Ten completed all aspects of the study. Interviews were conducted before and after a one-week period of non-participant observations and self-report tasks. The authors grouped emotional experiences into "positive" or "difficult" emotions. Data were analyzed for coherent themes using grounded theory and content analysis.
Positive emotions included gratitude, happiness, compassion, pride, and relief, and were triggered by connections with patients and colleagues, receiving recognition for one's labors, learning, being a part of modern medicine, and receiving emotional support from others. Difficult emotions included anxiety, guilt, sadness, anger, and shame and were triggered by uncertainty, powerlessness, responsibility, liability, lack of respect, and a difference in values. Tragedy and patients' suffering was the only trigger to elicit both positive (compassion) and difficult (sadness) emotions.
This study identified common and important emotions experienced by medical trainees and the common triggers for these emotions. Understanding trainees' experiences of uncertainty, powerlessness, differing values, and lack of respect can guide education program designs and reforms to create an environment that fosters professional growth.
This article explores the commitment of faculty to ethics training in psychiatric education. Although psychiatry has insufficiently addressed the profession's need for ethics training in education, program directors acknowledge its critical importance, and its positive impact has been demonstrated. Additionally, residents often seek ethics training as part of their instruction.
The author suggests that academic faculty could respond to the profession's inadequate treatment of ethics training by helping trainees develop moral agency--the ability to recognize, assess, and respond to ethical dilemmas; decide what constitutes right or wrong care; and act accordingly. The author also describes how this objective could be met by promoting professionalism and offering didactic instruction that address substantive and process issues regarding psychiatric care.
Specific recommendations are provided.
Personal, creative writing as a process for reflection on patient care and socialization into medicine ("reflective writing") has important potential uses in educating medical students and residents. Based on the authors' experiences with a range of writing activities in academic medical settings, this article sets forth a conceptual model for considering the processes and effects of such writing. The first phase (writing) is individual and solitary, consisting of personal reflection and creation. Here, introspection and imagination guide learners from loss of certainty to reclaiming a personal voice; identifying the patient's voice; acknowledging simultaneously valid yet often conflicting perspectives; and recognizing and responding to the range of emotions triggered in patient care. The next phase (small-group reading and discussion) is public and communal, where sharing one's writing results in acknowledging vulnerability, risk-taking, and self-disclosure. Listening to others' writing becomes an exercise in mindfulness and presence, including witnessing suffering and confusion experienced by others. Specific pedagogical goals in three arenas-professional development, patient care and practitioner well-being - are linked to the writing/reading/listening process. The intent of presenting this model is to help frame future intellectual inquiry and investigation into this innovative pedagogical modality.
The Harvard Medical School-Cambridge Integrated Clerkship (HMS-CIC) is a redesign of the principal clinical year to foster students' learning from close and continuous contact with cohorts of patients in the disciplines of internal medicine, neurology, obstetrics-gynecology, pediatrics, and psychiatry. With year-long mentoring, students follow their patients through major venues of care. Surgery and radiology also are taught longitudinally, grounded in the clinical experiences of a cohort of patients and in a brief immersion experience working directly with an attending surgeon. Students participate in weekly, case-based tutorials integrating instruction in the basic sciences with training to address the common and important issues in medicine, as identified by national organizations. In addition, they participate in a social science curriculum that focuses on self-reflection, communication skills, ethics, population sciences, and cultural competence. In the pilot year (July 2004 to July 2005), HMS-CIC students performed at least as well as traditional students in tests of content knowledge and skills, as measured by National Board of Medical Examiners (NBME) Subject Exams and the fourth-year Objective Structured Clinical Exam, and they scored higher on a year-end comprehensive clinical skills self-assessment examination, suggesting that they retained content knowledge better. From surveys, HMS-CIC students were much more likely to see patients before diagnosis and after discharge and to receive feedback and mentoring from experienced faculty than were their traditionally educated peers. HMS-CIC students expressed more satisfaction with their curriculum and felt better prepared to cope with the professional challenges of patient care, such as being truly caring, involving patients in decision making, and understanding how the social context affects their patients.
Objectives:
To explore potentials for avoiding humiliations in clinical encounters, especially those that are unintended and unrecognized by the doctor. Furthermore, to examine theoretical foundations of degrading behaviour and identify some concepts that can be used to understand such behaviour in the cultural context of medicine. Finally, these concepts are used to build a model for the clinician in order to prevent humiliation of the patient.
Theoretical frame of reference:
Empirical studies document experiences of humiliation among patients when they see their doctor. Philosophical and sociological analysis can be used to explain the dynamics of unintended degrading behaviour between human beings. Skjervheim, Vetlesen, and Bauman have identified the role of objectivism, distantiation, and indifference in the dynamics of evil acts, pointing to the rules of the cultural system, rather than accusing the individual of bad behaviour. Examining the professional role of the doctor, parallel traits embedded in the medical culture are demonstrated. According to Vetlesen, emotional awareness is necessary for moral perception, which again is necessary for moral performance.
Conclusion:
A better balance between emotions and rationality is needed to avoid humiliations in the clinical encounter. The Awareness Model is presented as a strategy for clinical practice and education, emphasizing the role of the doctor's own emotions. Potentials and pitfalls are discussed.
Efforts to promote medical professionalism often focus on cognitive and technical competencies, rather than professional identity, commitment, and values. The Healer's Art elective is designed to create a genuine community of inquiry into these foundational elements of professionalism.
Evaluations were obtained to characterize course impact and to understand students' conceptions of professionalism.
Qualitative analysis of narrative course evaluation responses.
Healer's Art students from U.S. and Canadian medical schools.
Analysis of common themes identified in response to questions about course learning, insights, and utility.
In 2003-2004, 25 schools offered the course. Evaluations were obtained from 467 of 582 students (80.2%) from 22 schools participating in the study. From a question about what students learned about the practice of medicine from the Healer's Art, the most common themes were "definition of professionalism in medicine" and "legitimizing humanism in medicine." The most common themes produced by a question about the most valuable insights gained in the course were "relationship between physicians and patients" and "creating authentic community." The most common themes in response to a question about course utility were "creating authentic community" and "filling a curricular gap."
In legitimizing humanistic elements of professionalism and creating a safe community, the Healer's Art enabled students to uncover the underlying values and meaning of their work--an opportunity not typically present in required curricula. Attempts to teach professionalism should address issues of emotional safety and authentic community as prerequisites to learning and professional affiliation.
Although many studies have explored the experiences of doctors in their first postgraduate year, few have focused on the ethical issues encountered by this group. Based on an extensive literature review of research involving house officers, we argue that these doctors encounter a broad range of 'everyday' ethical challenges, from truth-telling to working in non-ideal conditions. We propose a typology of house officers' ethical issues and advocate prioritizing these issues in undergraduate medical ethics and law curricula.
This paper argues that the professional situation of junior doctors is unique in ethically important ways and thus that ethics work focusing on junior doctors specifically is necessary. Unlike the medical student or the more senior doctor, the doctor in his or her early postgraduate years is simultaneously a responsible health professional, a subjugate learner and a human resource. These multiple roles generate the set of ethical issues faced by junior doctors, a set that has some overlaps with that faced by medical students and with that faced by more experienced doctors but is far from completely continuous with either. Further, the multiple roles that junior doctors play affect their options for negotiating the ethical challenges that they face. Their position determines not only the content of the set of ethical issues that they encounter, but also the kinds of actions they can take in the face of these challenges. Thus considering junior doctors only in combination with medical students or more senior doctors fails on two fronts. Firstly, only a very incomplete set of the ethical issues faced by junior doctors will be addressed, and, secondly, the constraints associated with the specific professional situation of junior doctors will not be adequately considered, limiting the practical applicability for these agents of any such analyses.
Medical student end-of-life care training provides insight into the hidden curriculum and physician professional development.
Second-year medical students at a university medical center listen to a panel discussion of 4th-year students and residents describing their end-of-life care experiences during clerkships. This discussion is intended to provide "anticipatory guidance" to 2nd-year students about challenging situations they might encounter on the wards. The purpose of this study was to analyze the content of the panel discussions by 4th-year students and residents to better understand their views of the end-of-life care curriculum.
We performed a qualitative content analysis of transcripts from 2 years of panel discussions. Participants' comments focused primarily on the complexity of the role of medical students in end-of-life care. Three major themes emerged in the sessions: defining professional identity, conflicting expectations, and limited medical experience.
The role of medical students in end-of-life care can be complex, confusing, and contradictory. Emotional support and elucidating the hidden curriculum may assist students with the process of physician enculturation and end-of-life care education.
ResearchGate has not been able to resolve any references for this publication.