Caring,competence and professional identities in medical education

This paper considers the multiple discourses that influence medical education with a focus on the discourses of competence and caring. Discourses of competence are largely constituted through, and related to, biomedical and clinical issues whereas discourses of caring generally focus on social concerns. These discourses are not necessarily equal partners in the enterprise of medical education. Discourses of competence tend to be privileged while those discourses of caring are often marginalised. Medical students learn to be physicians, and develop professional identities, in the context of these competing discourses. This paper documents a qualitative study designed to explore how professional identities are developed in the context of competing discourses. The study included a Foucauldian discourse analysis of medical education curriculum documents (67 problem-based learning cases in total), 26 h of observation of a small group learning experience (a problem-based learning tutorial), and in-depth, open-ended interviews with five medical students and nine medical educators at a Canadian medical school. The paper describes how professional identities are developed in relation to discourses of competence, noting that students displayed what they considered to be desirable professional identities of confidence, capability and suitability. Also explored are the professional identities demonstrated in relation to discourses of caring, including those of benevolence and humbleness. Despite current conceptualisations, medical education is ripe with potential. The data indicate Foucauldian “spaces of freedom”—sites at which the complexity of the practice of medicine and the interwoven natures of the discourses of competence and caring might be taken into account as a means of challenging taken for granted cultural norms and broadening the medical gaze.     

Analysing the hidden curriculum: use of a cultural web

CONTEXT  Major influences on learning about medical professionalism come from the hidden curriculum. These influences can contribute positively or negatively towards the professional enculturation of clinical students. The fact that there is no validated method for identifying the components of the hidden curriculum poses problems for educators considering professionalism. The aim of this study was to analyse whether a cultural web, adapted from a business context, might assist in the identification of elements of the hidden curriculum at a UK veterinary school. METHODS  A qualitative approach was used. Seven focus groups consisting of three staff groups and four student groups were organised. Questioning was framed using the cultural web, which is a model used by business owners to assess their environment and consider how it affects their employees and customers. The focus group discussions were recorded, transcribed and analysed thematically using a combination of a priori and emergent themes. RESULTS  The cultural web identified elements of the hidden curriculum for both students and staff. These included: core assumptions; routines; rituals; control systems; organisational factors; power structures, and symbols. Discussions occurred about how and where these issues may affect students’ professional identity development. CONCLUSIONS  The cultural web framework functioned well to help participants identify elements of the hidden curriculum. These aspects aligned broadly with previously described factors such as role models and institutional slang. The influence of these issues on a student’s development of a professional identity requires discussion amongst faculty staff, and could be used to develop learning opportunities for students. The framework is promising for the analysis of the hidden curriculum and could be developed as an instrument for implementation in other clinical teaching environments.     

Hidden curriculum in continuing medical education

In developing curricula for undergraduate and graduate medical education, educators have become increasingly aware of an interweaving of the formal, informal, and hidden curricula and their influences on the outcomes of teaching and learning. But, to date, there is little in the literature about the hidden curriculum of medical practice, which takes place after graduation and certification. This article initiates that discussion with influences of the hidden curriculum on the actions physicians take or do not take in caring for patients. Hafferty's framework of institutional policies, evaluation activities, resource-allocation decisions, and institutional slang, along with our knowledge of health services research and the continuing medical education (CME) research literature, suggests that there is a hidden and powerful curriculum that affects physician performance. Determining whether the hidden curriculum conflicts with the messages that we are delivering through formal CME (courses, clinical practice guidelines, peer review journals) may contribute to improving our impact on physician performance.     

The pursuit of medical knowledge and the potential consequences of the hidden curriculum

This study explores how preclinical medical students experience particular elements of their training, specifically their pursuit for medical knowledge and how this may impact their attributes as well as their relations with those outside of the realm of medicine. Ten first-year and 10 second-year students of a US medical school were interviewed regarding their experiences with and perceptions of their medical training. The students reported a cognitive and emotional distance from non-medical students that appears to be accentuated not only by their strenuous academic responsibilities but also elements of the hidden curriculum nested within medical training. Furthermore, students discuss experiencing disapproval, mistrust, and negative judgment toward laypersons thereby suggesting that this distancing may lend to deleterious effects on students' ability and willingness to connect with others. A Parsonian lens is utilized to examine the notion of a 'Knowledge Gap' as well as aspects of the hidden curriculum in medical education and their role in professionalizing medical students.     

Teaching medical ethics: A review of the literature from North American medical schools with emphasis on education

Efforts to reform medical education have emphasized the need to formalize instruction in medical ethics. However, the discipline of medical ethics education is still searching for an acceptable identity among North American medical schools; in these schools, no real consensus exists on its definition. Medical educators are grappling with not only what to teach (content) in this regard, but also with how to teach (process) ethics to the physicians of tomorrow. A literature review focused on medical ethics education among North American medical schools reveals that instruction in ethics is considered to be vitally important for medical students. Agreement by medical educators on a possible “core curriculum” in ethics should be explored. To develop such a curriculum, “deliberative curriculum inquiry” by means of a targeted Delphi technique may be a useful methodology. However, the literature reveals that medical curricular change is notoriously slow. General implications for medical ethics education as a discipline are discussed. This revised version was published online in July 2006 with corrections to the Cover Date.     

Constructing and Communicating Privacy Boundaries: How Family Medicine Physicians Manage Patient Requests for Religious Disclosure in the Clinical Interaction

Religion/spirituality (R/S) is an important component of some patients’ psychosocial framework when facing illness. While many patients report an increased desire for R/S dialogue in clinical interaction, especially when facing a frightening diagnosis, some physicians report discomfort talking about R/S and hold various beliefs regarding the appropriateness of such discussions. Not only do physicians manage conversations centering on patient disclosures in the clinical visit, they must also navigate requests to share their own personal information. Farber et al. (2000) found that over a 12-month period nearly 40% of physicians reported that patients asked questions that transgressed professional boundaries. This article uses Petronio’s communication privacy management theory as a lens through which to situate our understanding of how family medicine physicians construct and communicate privacy boundaries in response to patient requests for religious disclosure. Results provide an in-depth theoretical understanding of issues surrounding religious disclosure in the medical visit and expand the discussion on health care providers’ personal and professional privacy boundaries as documented by Petronio and Sargent (2011). Implications for health care training and practice are discussed.     

Exposure of medical students to pharmaceutical marketing in primary care settings: frequent and influential

It is known that interaction between pharmaceutical companies and medical professionals may lead to corruption of professional values, irrational use of medicine, and negative effects on the patient–physician relationship. Medical students frequently interact with pharmaceutical company representatives and increasingly accept their gifts. Considering the move toward early clinical encounters and community-based education, which expose students early to pharmaceutical representatives, the influence of those gifts is becoming a matter of concern. This study examines the frequency and influence of student exposure to drug marketing in primary care settings, as well as student perceptions of physician–pharmaceutical company relationships. This was a two-phase study consisting of qualitative research followed by a cross-sectional survey. Clinical experience logbooks of 280 second-year students in one school were analysed, and the themes that emerged were used to develop a survey that was administered to 308 third-year students from two medical schools. Survey results showed a 91.2% exposure to any type of marketing, and 56.8% of students were exposed to all classes of marketing methods studied. Deliberate targeting of students by pharmaceutical representatives, in particular, was correlated with being less sensitive to the negative effects of and having positive opinions about interactions with pharmaceutical companies. The vast majority of students are exposed to drug marketing in primary care settings, and may become more vulnerable to that strategy. Considering that medical students are vulnerable and are targeted deliberately by pharmaceutical companies, interventions aimed at developing skills in the rational use of medicines and in strategies for coping with drug marketing should be devised.     

Thanatophobia and opiophobia of hospice nurses compared with that of other caregivers

In meeting national needs for our terminally ill, health care educators need to become more aware of their students' aptitudes for hospice work. For these reasons we measured hospice nurses' attitudes toward caring for the terminally ill and their views on using opioids, and compared them to those of other health care personnel and their students. Thirty-eight hospice nurses, 64 other nurses, 93 physicians, and 676 senior medical students participated in this study. Our primary measures were scales assessing thanatophobia and opiophobia and a battery of personal and professional role trait measures. Our results indicated that in providing end-of-life care, hospice nurses expressed less discomfort, helplessness, and frustration, and indicated less reluctance to use opioids than did any of the other groups surveyed. Overall, these hospice nurses had 35 percent lower opiophobia and 55 percent lower thanatophobia scores than the other health care professionals. Despite dealing with issues of death and dying on a daily basis, hospice nurses also scored lower on depressed mood. In caring for the terminally ill, hospice nurses' other personal traits were also less maladaptive than those of the other health professionals. Psychiatrists exhibited the most opiophobia, not only scoring higher than physicians practicing oncology, but also higher than senior medical students. To assure cancer patients that they can expect to live their lives free of pain, medical educators can use these thanatophobia and opiophobia scales to develop better teaching, counseling, and monitoring strategies.     

On whose shoulders we stand: lessons from Exemplar medical educators

The hiring of educators in medical schools (faculty who study the educational process and prepare others to become educators) has been one of the most successful educational innovations ever. Starting in 1954, through a collaboration between the Schools of Medicine and Education at the University of Buffalo, the innovation has spread to over half of the medical schools in the United States and to medical schools in several other countries. Practically every medical school and specialty now hires educators to conduct faculty development, evaluate learners, and develop or revise curricula. This article focuses on lessons learned by six-first-generation educators hired in medical education. These individuals made unique contributions that improved the process of educating and evaluating future physicians. Among their most important contributions have been the use of standardized patients, faculty development to improve instruction, and the use of clinical decision making theory. In addition, these professional educators created a home and career path for other professionals and nurtured protégés to continue the work they started. Ten lessons are reported from structured interviews using a standardized protocol. These lessons will hopefully inform current and future medical educators to help them sustain the effective collaboration between medical schools and educators.     

A critical time for medical education: the perils of competence-based reform of the curriculum

Rapid expansion in scientific knowledge, changes in medical practice, and greater demands from patients and society necessitate reform of the medical curriculum. In recognition of this, medical educators across the world have recommended the adoption of competence-based education. This is intended to increase the rigour and relevance of the curriculum, move students beyond a focus on the memorisation and regurgitation of scientific facts, and better enable them to understand scientific principles and apply them to the practice of medicine. Experience from 40 years’ use of competence-based curricula across the world suggests that the uncritical application of this approach to the medical curriculum may not achieve its intended aims. There are valuable lessons to be learnt from the history of competence-based education. By taking on board these lessons, confronting the pitfalls of this approach, and devising new and creative solutions to the problems inherent in this methodology, medical educators can better achieve their aim of providing a strong foundation for the practice of medicine in the twenty-first century. It is only through such a strategy—rather than the uncritical adoption of this educational approach—that we will have real movement and progress both in competence-based education in general, and in its applications to medicine in particular.     

Medical students’ emotional development in early clinical experience: a model

Dealing with emotions is a critical feature of professional behaviour. There are no comprehensive theoretical models, however, explaining how medical students learn about emotions. We aimed to explore factors affecting their emotions and how they learn to deal with emotions in themselves and others. During a first-year nursing attachment in hospitals and nursing homes, students wrote daily about their most impressive experiences, explicitly reporting what they felt, thought, and did. In a subsequent interview, they discussed those experiences in greater detail. Following a grounded theory approach, we conducted a constant comparative analysis, collecting and then interpreting data, and allowing the interpretation to inform subsequent data collection. Impressive experiences set up tensions, which gave rise to strong emotions. We identified four ‘axes’ along which tensions were experienced: ‘idealism versus reality’, ‘critical distance versus adaptation’, ‘involvement versus detachment’ and ‘feeling versus displaying’. We found many factors, which influenced how respondents relieved those tensions. Their personal attributes and social relationships both inside and outside the medical community were important ones. Respondents’ positions along the different dimensions, as determined by the balance between attributes and tensions, shaped their learning outcomes. Medical students’ emotional development occurs through active participation in medical practice and having impressive experiences within relationships with patients and others on wards. Tensions along four dimensions give rise to strong emotions. Gaining insight into the many conditions that influence students’ learning about emotions might support educators and supervisors in fostering medical students’ emotional and professional development.     

Health promotion beliefs and practices of fourth-year medical students

Little is known about medical student beliefs about health promotion issues or about their prevention practices with patients. We administered a questionnaire about health promotion beliefs and practices to fourth-year medical students in a required course, "Preventive Medicine in Clinical Practice," at the University of Maryland School of Medicine. During a three-year period we surveyed 343 students. A majority of students believed that most of 23 health behaviors were of some importance to health promotion, and their responses were similar to those of practicing physicians in prior studies. Most students reported that they assessed preventive practices in their patients but did not feel well prepared to counsel patients about health issues. Students reported they were currently unsuccessful in modifying patient health behaviors and expressed limited optimism about future success in helping patients change health promotion behaviors with further training and support. There were no differences between students entering primary care specialties and other students. Information about medical student health promotion and disease prevention beliefs and practices can be applied in curriculum development.     

Student perceptions of medico-legal autopsy demonstrations in a student-centred curriculum

Objectives  Teaching autopsies in undergraduate medicine, although traditionally considered valuable by both educators and students, have been marginalised in modern curricula. This study explored medical students' experiences of the medico-legal autopsy demonstrations which formed part of their training in forensic medicine.
Methods  In this phenomenological study, qualitative data obtained by interviewing 10 Year 4 medical students from various socio-cultural backgrounds were interpretively examined. One-to-one, semi-structured interviews were tape-recorded and transcribed. The data were thematically organised and then analysed using a theoretical framework of three dimensions of learning, namely, cognitive, emotional and societal.
Results  Students still perceive autopsies as essential even in the context of self-directed learning. They identified a better understanding of anatomy and traumatology as the main cognitive benefits. At an emotional level students felt they had developed a degree of clinical detachment and would be better equipped to deal with issues surrounding death. Although socialisation influenced students' feelings about the autopsy, it did not detract from their appreciation of the educational value of the experience.
Conclusions  The results support previous findings from both students, prior to curriculum reform, and medical educators who were canvassed for their opinions in relation to a modern curriculum. Besides the obvious cognitive advantages, educators should be mindful of the hidden curriculum that emanates from autopsies because it impacts on the development of professionalism and ethical behaviours of future medical practitioners.     

Social,health care and rehabilitation educators' competence in professional education—Empirical testing of a model

The social and health care educator's role in educating future professionals need to be stronger emphasised and deserves international recognition. The purpose of this study was to develop and test an empirical model of social and health care educators' competence in higher and professional education. The presented research employed a cross-sectional study design. Data were collected using HeSoEduCo-instrument from 28 educational institutions in Finland. The model was empirically tested with confirmatory factor analysis through Structural Equation Modelling that applied the Full Imputation Maximum Likelihood estimator. A total of 422 social and health care educators participated in the study. The empirical model of social and health care educators including eight competence areas: leadership and management, collaboration and societal, evidence-based practice, subject and curriculum, mentoring students in professional competence development, student-centred pedagogy, digital collaborative learning, and cultural and linguistic diversity. All of the connections between concepts of the empirical model were found to be statistically significant. There were strong connections between most of the identified competence concepts; however, two weak connections were found, namely, the link between competence in evidence-based practice and competence in subject and curriculum, along with the link between competence in digital collaborative learning and competence in student-centred pedagogy. The presented empirical model can help stakeholders identify which areas of social and health care educators' curricula should be further developed. The model is also relevant for improving continuous education, allowing educators to assess their competence levels and evaluating educators' performance at the organisational level.     

Real life narratives enhance learning about the ‘art and science’ of midwifery practice

Health professional educators have long grappled with how to teach the more elusive art of practice alongside the science (a term that encompasses the sort of professional knowledge that can be directly passed on). A competent practitioner is one who knows when, how and for whom to apply knowledge and skills, thereby making the links between theory and practice. They combine art and science in such a way that integrates knowledge with insight. This participatory hermeneutic study explored the experience of teachers and students of implementing a narrative-centred curriculum in undergraduate midwifery education. It revealed that when real life narratives were central to the learning environment, students’ learning about the art of midwifery practice was enhanced as they learned about midwifery decisions, reflected on their own values and beliefs and felt an emotional connection with the narrator. Further, art and science became melded together in the context specific wisdom of practice (phronesis).     

The relationship between social support,shared decision-making and patient’s trust in doctors: a cross-sectional survey of 2,197 inpatients using the Cologne Patient Questionnaire

Objectives  

Empirical studies have confirmed that a trusting physician–patient interaction promotes patient satisfaction, adherence to treatment and improved health outcomes. The objective of this analysis was to investigate the relationship between social support, shared decision-making and inpatient’s trust in physicians in a hospital setting.     

Helping medical learners recognise and manage unconscious bias toward certain patient groups

Medical Education 2012: 46: 80–88 Context For the last 30 years, developments in cognitive sciences have demonstrated that human behaviour, beliefs and attitudes are shaped by automatic and unconscious cognitive processes. Only recently has much attention been paid to how unconscious biases based on certain patient characteristics may: (i) result in behaviour that is preferential toward or against specific patients; (ii) influence treatment decisions, and (iii) adversely influence the patient–doctor relationship. Partly in response to accreditation requirements, medical educators are now exploring how they might help students and residents to develop awareness of their own potential biases and strategies to mitigate them. Methods In this paper, we briefly review key cognition concepts and describe the limited published literature about educational strategies for addressing unconscious bias. Discussion We propose a developmental model to illustrate how individuals might move from absolute denial of unconscious bias to the integration of strategies to mitigate its influence on their interactions with patients and offer recommendations to educators and education researchers.     

Teacher beliefs, professional preparation, and practices regarding exceptional students and sexuality education

Sexuality education, part of the comprehensive school health education component of a Coordinated School Health Program, interests many health educators as well as special education teachers. In this study, Florida special educators reported their beliefs about teaching sexuality education to educable mentally disabled students, the range of sexuality topics they teach, and their professional preparation in sexuality education. Respondents (n = 494) completed a mailed instrument that included the 36 sexuality content areas identified by the Sexuality Information and Education Council of the United States. Respondents believed strongly that many of the sexuality topics and content areas should be taught to educable mentally disabled students. However, most reported delivering only a modest amount of sexuality education, and they rated their professional preparation as inadequate. Regression analyses documented that respondents' beliefs predicted the topics they actually taught within 5 of the 6 key concepts. This study supports collaboration between health educators and special education teachers to adapt existing sexuality curricula for students with special needs, improve professional preparation of special education teachers to teach sexuality education, and to more effectively implement comprehensive school health education through the Coordinated School Health Program model to special education students.