Tolerance of ambiguity,perfectionism and resilience are associated with personality profiles of medical students oriented to rural practice

Purpose: Resilience, coping with uncertainty and learning from mistakes are vital characteristics for all medical disciplines – particularly rural practice. Levels of coping constructs were examined in medical students with and without a rural background or an interest in rural practice.

Methods: Cross-sectional surveys identified two personality profiles, and their association with levels of Tolerance of Ambiguity, Resilience, Perfectionism-High Standards and Concern over mistakes as constructs indicative of coping. Medical students (N?=?797) were stratified by rural background and degree of rural interest. Mediation analysis tested the effect of personality profile on levels of the coping constructs.

Results: More (72%) rural background students had Profile 1 which was associated with higher levels of Tolerance of Ambiguity, High standards, and Resilience, but lower Concern over mistakes. Non-rural background students reporting a strong rural interest also had Profile 1 (64%) and similar levels of coping constructs. Personality profile mediated the association between rural interest and levels of coping constructs regardless of background.

Conclusions: Having a rural background or strong rural interest are associated with a personality profile that indicates a better capacity for coping. Personality may play a part in an individual’s interest in rural practice. Rural workforce initiatives through education should encourage and nurture students with a genuine interest in rural practice – regardless of background.     

Observations of physician, patient and family perceptions of informed consent in Houston, Texas

Informed consent is one of the most important ethical and legal principles in the United States, including Texas, and reflects a profound respect for individuals and their ability to make decisions in their own best interest. It is also a critical underpinning of medical practice, although how it is actually carried out has not been well studied. A survey was conducted in the private practices and a hospital in the Texas Medical Center in Houston, Texas to ascertain how physicians, patients and patient's family members perceive and demonstrate the elements of informed consent. In-depth interviews of twelve physicians, three patients and three family members were carried out. For physicians, consent was an explicit and implicit aspect of virtually all medical practice. Physicians would seek patient input concerning medical decisions whenever possible and might also discuss care choices with families. However, they often made decisions based upon what they perceived as the patient's best interests. Patients expected the physician to involve them in the decision process, but whether they turned to family members, or even others to assist them, varied considerably. Although Texas physicians respect the competent patient as the primary decision maker, they may bypass a formal surrogate decision maker to gain input from others, including their own view of what is in the patient's best interest.     

The CeMENT project: a case study in change management

The Community Based Medical Education in North Thames (CeMENT) Project case study is a useful approach to analysing complex change facing the medical profession and all medical teachers. The project was a collaboration involving five North London medical schools to develop the community-based aspects of the undergraduate medical curriculum. The project management team was drawn from academic general practitioners, hospital specialists with expertise in medical education, and education. Complex change involving partnerships across organizational and functional boundaries is often extremely challenging in terms of coordination and management owing to its unpredictability and ownership problems. Success in change management could be enhanced by use of a framework that includes a clear statement of purpose, stakeholder concordance and trust, clear leadership and structures, and fast action together with recognition of achievements.     

Nonfeeding: lawful killing in CA, homicide in NJ

Appellate courts in California and New Jersey have reached conflicting conclusions in the first legal tests of whether artificial feeding is a "medical treatment," and whether it is ever legally permissible to allow a patient to die from dehydration or starvation. In a criminal prosecution of physicians Robert Nejdl and Neil Barber, the California court ruled that there was no significant difference between a respirator and intravenous feeding, and that the two doctors had no legal duty to continue "futile" treatment of their irreversibly comatose patient. The New Jersey court rejected as purposeful killing a request to remove the nasogastric tube from elderly nursing home patient Claire Conroy, who was incompetent but not comatose. Annas considers the issue of pain or suffering to be central to decision making in such cases.     

Epistemic trust, epistemic responsibility, and medical practice

Epistemic trust is an unacknowledged feature of medical knowledge. Claims of medical knowledge made by physicians, patients, and others require epistemic trust. And yet, it would be foolish to define all epistemic trust as epistemically responsible. Accordingly, I use a routine example in medical practice (a diagnostic test) to illustrate how epistemically responsible trust in medicine is trust in epistemically responsible individuals. I go on to illustrate how certain areas of current medical practice of medicine fall short of adequately distinguishing reliable and unreliable processes because of a failure to systematically evaluate health outcomes. I conclude by articulating the devastating obstacles to the consilience assumption, which takes intellectual character (rather than reliable belief-forming processes) as the standard for epistemic responsibility.     

Twelve tips for choosing and surviving a PhD in medical education – a student perspective

The decision to undertake a PhD in medical education could mark a critical point in defining your future career. Attaining the highest level of degree in such a diverse and rewarding area as medical education may not only provide you with an opportunity to undertake important new research, but could also unlock different job opportunities. As is often the case, such rewards are not gained lightly. There can be real challenges in making the decision to undertake and then to successfully navigate a PhD. The specific subject and process of each doctorate is unique, leaving many prospective and current students uncertain as to what to expect. We offer our twelve tips from the perspective of two current PhD students to help guide those who share our interest in medical education and are considering doctoral study.     

Entrustable professional activities (EPAs) for teachers in medical education: Has the time come?

On a daily basis, patients put their trust in the healthcare system for safe and high-quality healthcare. However, what evidence do we have as an educational community that our supervising faculty members are competent to fulfill this responsibility? Few, if any, requirements exist for faculty members to have continuous professional development in the field of medical education. Many faculty “love to teach”, however, this love of teaching does not make them competent to teach or assess the competence of trainees whom they supervise. Faculty members who have a significant role as a teacher in the clinical setting should be assessed with regards to their baseline competence in applicable teaching EPAs. When competence is reached, an entrustment decision can be made. Once proficient or expert, a statement of awarded responsibility (STAR) may be granted. The time has come to reach beyond the “standards” of the old adage “see one, do one, teach one” in medical education. In this personal view, the authors outline an argument for and list the potential benefits for teachers, learners, and patients when we assess clinical teachers using EPAs within a competency-based medical education framework.     

Perceptions of long-term care, autonomy, and dignity, by residents, family and care-givers: the Houston experience

Houston, Texas, is a major U.S. city with, like many, a growing aging population. The purpose of this study and ultimate book chapter is to explore the views and perceptions of long-term care (LTC) residents, family members and health care providers. Individuals primarily in independent living and group residential settings were interviewed and studied. Questions emphasized the concepts of personal autonomy, dignity, quality and location of care and decision making. Although a small sample of participants were involved, consistency was noted. Keeping the elderly in caring and loving home situations (theirs or family) was most preferred. Personal choice and independence were emphasized by residents, but family members needed to act as advocates. We also noted that the legal system emphasizes family control over individual decision making as competency declines with aging. Optimal personal decision making in the residents' best interest also became more difficult with loss of individual mental capacity.     

Barriers to organ procurement: why donor cards fail

A recent nationwide survey (see Thomas D. Overcast, et al., "Problems in the identification of potential organ donors," Journal of the American Medical Association, 23-30 March 1984) found a lack of effective state and hospital programs for using donor cards in organ procurement. Although the Uniform Anatomical Gift Act recognizes such cards as legal evidence of a person's intention to donate, physicians cite legal and ethical reasons for requiring family approval before organ removal. The study recommended greater government involvement in organ procurement, stronger legislation to remove perceived legal problems, and education of the medical community and the public to lessen ethical objections.     

CharlesTaylor, phronesis, and medicine: ethics and interpretation in illness narrative

This paper provides a brief overview and critique of the dominant objectivist understanding and use of illness narrative in Enlightenment (scientific) medicine and ethics, as well as several revisionist accounts, which reflect the evolution of this approach. In light of certain limitations and difficulties endemic in the objectivist understanding of illness narrative, an alternative phronesis approach to medical ethics influenced by Charles Taylor's account of the interpretive nature of human agency and language is examined. To this end, the account of interpretive medical responsibility previously described by Schultz and Carnevale as "clinical phronesis" (based upon Taylor's notion of "strong" or "radical evaluation") is reviewed and expanded. The thesis of this paper is that illness narrative has the ability to benefit patients as well as the potential to cause harm or iatrogenic effects. This benefit or harm is contingent upon how the story is told and understood. Consequently, these tales are not simply "nice stories," cathartic gestures, or mere supplements to scientific procedures and decision making, as suggested by the objectivist approach. Rather, they open the agent to meanings that provide a context for explanation and evaluation of illness episodes and therapeutic activities. This understanding provides indicators (guides) for right action. Hence, medical responsibility as clinical phronesis involves, first, the patient and provider's coformulation and cointerpretation of what is going on in the patient's illness narrative, and second, the patient and provider's response to interpretation of the facts of illness and what they signify-not simply a response to the brute facts of illness, alone. The appeal to medical responsibility as clinical phronesis thus underscores the importance of getting the patient's story of illness right. It is anticipated that further elaboration concerning the idea of clinical phronesis as interpretive illness narrative will provide a new foundation for medical ethics and decision making.     

Trust,Risk, and Race in American Medicine

There is ample evidence that patient mistrust toward the American medical system is to some extent associated with communal and individual experiences of racism. For groups who have faced exploitation and discrimination at the hands of physicians, the medical profession, and medical institutions, trust is a tall order and, in many cases, would be naive. Nevertheless, trust is often regarded as a central feature of the physician-patient relationship. In this article, I draw on empirical research, ethical theory, and clinical cases to propose one way that providers might address and, ideally, resolve mistrust when it arises in an immediate case. I describe how medical mistrust has been characterized empirically within medical and bioethics scholarship, and I provide an overview of theories of trust, arguing that they may be unable to account for the risks that providers must take in seeking to establish trust within many American medical institutions. Common assumptions in medical and bioethical scholarship on trust notwithstanding, caring and competence are not always enough to establish a trusting relationship between physician and patient. I suggest that, in an atmosphere of mistrust, comprehension of the existence and source of suspicion is essential to effective signaling of trustworthiness.     

The evolution of integration: innovations in clinical skills and ethics in first year medicine

Critical self-reflection, medical ethics and clinical skills are each important components of medical education but are seldom linked in curriculum development. We developed a curriculum that builds on the existing integration of ethics education into the clinical skills course to more explicitly link these three skills. The curriculum builds on the existing integration of clinical skills and ethics in first year medicine. It refines the integration through scheduling changes; adds case studies that emphasise the social, economic and political context of our province's patient population; and introduces reflection on the "culture of medicine" as a way to have students articulate and understand their own values and moral decision making frameworks. This structured Clinical Skills course is a model for successfully integrating critical self-reflection, reflection on the political, economic and cultural contexts shaping health and healthcare, and moral decision making into clinical skills training.     

BEME Guide No. 1: Best Evidence Medical Education

There is a need to move from opinion-based education to evidence-based education. Best evidence medical education (BEME) is the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. It involves a professional judgement by the teacher about his/her teaching taking into account a number of factors-the QUESTS dimensions. The Quality of the research evidence available-how reliable is the evidence? the Utility of the evidence-can the methods be transferred and adopted without modification, the Extent of the evidence, the Strength of the evidence, the Target or outcomes measured-how valid is the evidence? and the Setting or context-how relevant is the evidence? The evidence available can be graded on each of the six dimensions. In the ideal situation the evidence is high on all six dimensions, but this is rarely found. Usually the evidence may be good in some respects, but poor in others.The teacher has to balance the different dimensions and come to a decision on a course of action based on his or her professional judgement.The QUESTS dimensions highlight a number of tensions with regard to the evidence in medical education: quality vs. relevance; quality vs. validity; and utility vs. the setting or context. The different dimensions reflect the nature of research and innovation. Best Evidence Medical Education encourages a culture or ethos in which decision making takes place in this context.     

Medical education in Turkey: past to future

Although medical education in the Republic of Turkey appears to be relatively new, there is almost 500 years of background development within the Anatolian region. Turkey has faced many difficulties in its past and present times, related to its vast and diverse geography, its crowded population, and the many ethnic groups that constitute its population. As in many other countries throughout the world, medical education in Turkey has recently been debated, reviewed and renewed. This article gives a general overview of the history of medical education and the present situation in Turkish medical schools; the quality and professionalism of medical education within the medical system, from the perspectives of undergraduate, postgraduate and continuing medical education; and an overview of the challenges and opportunities that presently exist.     

Evidence, logic, the rule and the exception in Renaissance law and medicine

This article sets out to investigate aspects of the uptake of Renaissance law and medicine from some of the logical and natural-philosophical components of the university arts course. Medicine is shown to have a much laxer operative logic than law, reflecting its commitment to the theory of idiosyncrasy as opposed to the demands made upon the law by the need for a uniform application of justice. Symptomatic of the different uptake are the contrasting meanings of "regulariter" and "generaliter" in the two disciplines. Whereas the law treats the rule as inviolable and the exception as only valid if made explicit in due legal form, medicine is able to conceive of a nature as a field of knowledge broader than that encompassed by its rules of art. Both law and medicine approach evidence in ways which reflect their attempts to keep apart the process of information-gathering from that of interpretation; this is exemplified by the legal computation of competing testimony on the one hand and by the various medical modes of sign interpretation on the other.     

AMEE Guide No. 123 – How to read studies of educational costs

Healthcare and health professions education share many of the same problems in decision making. In both cases, there is a finite amount of resources, and so choices need to be made between alternatives. To navigate the options available requires effective decision making. Choosing one option requires consideration of its opportunity cost – the benefit forgone of the other competing options. The purpose of this abridged AMEE guide is to introduce educational decision-makers to the economic concept of cost, and how to read studies about educational costs to inform effective cost-conscious decision-making. This guide leads with a brief review of study designs commonly utilized in this field of research, followed by an overview of how study findings are commonly presented. The tutorial will then offer a four-step model for appraising and considering the results of an economic evaluation. It asks the questions: (1) Can I trust the results? (2) What are the results telling me? (3) Could the results be transferred to my context? (4) Should I change my practice?     

Better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships

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.     

Beyond decision making: class, community organizations, and the healthwork of people living with HIV/AIDS. Contributions from institutional ethnographic research

The consolidation of antiretroviral therapy as the primary biomedical response to HIV infection in the global North has occasioned a growing interest in the health decision making of people living with HIV (PHAs). This interest is burdened by the weight of a behaviorist theoretical orientation that limits decision making to individual acts of rational choice. This article offers an alternative way to understand how PHAs come to take (or not take) biomedical treatments. Drawing on institutional ethnographic research conducted in Toronto, Canada, it explores how the "healthwork" of coming to take (or not take) treatments is organized by extended relations of biomedical knowledge. The article focuses on two aspects of the knowledge relations of coming to take pharmaceutical medications that transcend the conceptual and relational terrain of rational decision-making perspectives. First, it explores disjunctures between the everyday healthwork of poor, socially marginalized PHAs and the terms of biomedical decision making. Second, it investigates the knowledge-mediating activities of community-based organizations that help mitigate those disjunctures.     

Stomach and psyche: eating, digestion, and mental illness in the medicine of Philippe Pinel

In premodern medicine eating and digestion were often linked to psychic disturbance, yet modern "mental medicine" is generally thought to have abandoned this ancient assumption. The work of Philippe Pinel, founder of French psychiatry and advocate of the "moral treatment," has been regarded as indicative of this process, but in fact eating and digestion remained important to Pinel's understanding of the néuroses, the variety of disease within which he classified both mild and severe forms of mental illness. Pinel's theoretical and clinical innovations in regard to maladies that blended mental and gastric distress left an important legacy both to asylum-based psychiatry and to medical generalists working in private settings in the nineteenth century. Today his work remains valuable for its insistence on the inextricability of the "physical and the moral" in psycho-gastric illness.