Applying activity theory to undergraduate medical curriculum reform: Lessons in contradictions from multiple stakeholders' perspectives.

PURPOSE: Medical school curricula require regular updating. We adopted an activity theory lens to conduct a holistic, multiple stakeholder-informed analysis of curricular reform, aiming to understand how the social relations between groups contribute to unanticipated tensions and outcomes. METHODS: A research assistant conducted semi-structured interviews with purposively sampled (N = 19) administrative staff, faculty course leads, faculty tutors, curriculum developers, change leaders and student leaders. The team applied a framework analysis to guide within and between stakeholder comparisons. RESULTS: Participants reported unique (N = 21) and cross-cutting (N = 17) contradictions underscoring emerging drivers of current and potential change. Unique contradictions raised by 1-2 groups represented seeds of change that had the potential to spread across all groups. By contrast, two general types of cross-cutting contradictions arose when one group had a dominant, confirming voice or two or more groups had contrasting perspectives. CONCLUSIONS: While finding contradictions was expected, our analysis profiled their nature and some of the specific tensions they raised across and within stakeholder groups. The activity theory lens provided an accessible way to unravel curricular reform into manageable units of analysis. Systematically identifying contradictions arising from curricular reform will help stakeholders collaborate with a shared purpose toward positive, sustained change.

Diagnostic Imaging and Mechanical Objectivity in Medicine.

BACKGROUND: Before the advent of automatism in image-making practices, scientists, anatomists, and physicians artistically depicted simplified images for scientific atlas making. This technique conferred subjectivity to a supposedly objective scientific process, sparking confrontations between anatomists regarding accuracy that heralded a new concept in the late 19th century - mechanical objectivity - that would revolutionize scientific knowledge and the field of medicine OBJECTIVES: The purpose of this health history research study is to trace the evolution of mechanical objectivity from empirical studies of early anatomists in the 19th century to the advent of x-ray technology, digitization of imaging, and disruptive technological innovations such as artificial intelligence, while simultaneously unveiling the challenges of mitigating human bias, despite advancements in medical imaging practices. METHODS: This narrative literature review was conducted using the Scopus® database under the guidance of both medical historians and practicing physicians to ensure its applicability and historical accuracy CONCLUSION: Despite a century-long quest for optimizing mechanical objectivity in diagnostic imaging to more accurately and efficiently interpret medical images, human bias remains an important factor. This historical review describes the development of medical imaging technologies over the last century with emphasis on the role played by human bias and subjectivity in a rapidly expanding field of medical imaging technology including artificial intelligence.

From Pandemic to Progression: An Educational Framework for the Implementation of Virtual Mental Healthcare for Children and Youth as a Response to COVID-19.

COVID-19 restrictions have necessitated child/youth mental health providers to shift towards virtually delivering services to patients' homes rather than hospitals and community mental health clinics. There is scant guidance available for clinicians on how to address unique considerations for the virtual mental healthcare of children and youth as clinicians rapidly shift their practices away from in-person care in the context of the COVID-19 pandemic. Therefore, we bridge this gap by discussing a six-pillar framework developed at Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada, for delivering direct to patient virtual mental healthcare to children, youth and their families. We also offer a discussion of the advantages, disadvantages, and future implications of such services.

From hermeneutics to heteroglossia: 'The Patient's View' revisited.

This article explores conceptual and methodological challenges surrounding the recovery of patients' voices in the history of medicine. We examine the debate that followed Roy Porter's seminal article, 'The Patient's View: Doing Medical History from Below' (1985). Porter argued that patients should be given a central role in medical history, aiming to restore to patients a voice and agency that is often lost in 'physician-centered' historical narratives. His work carried significant influence but also sparked an ongoing debate about the possibility of conducting 'patient-centered' history of medicine. The growth of the medical humanities has afforded renewed attention to patient narratives, supporting the need to recognise patients' voices in contemporary healthcare and medical education. However, several barriers complicate and problematise the expansion of a patient-centred epistemology across historical periods. Postmodern critics have expressed scepticism that 'the patient's view' can be recovered from history, with some claiming that 'the patient' is a construct of the 'medical gaze' whose subjectivity cannot be reconstituted outside of sociohistorical discourses of knowledge and power. Psychiatry in the mid-20th century presents a particular challenge for patient-centred history. We discuss the influence of postmodern theorists, especially Michel Foucault, whose work is seen as undermining the possibility of a patient-centred epistemology. We argue against Foucault's erasure of the patient, and instead explore alternate constructivist epistemologies, focusing on the hermeneutics of Hans-Georg Gadamer and dialogism of Mikhail Bakhtin, to help address historiographical challenges in recovering 'the patient's view'. To illustrate the value of Gadamerian and Bakhtinian approaches, we apply them to a case study from the Verdun Protestant Hospital (Québec, Canada) from 1941 to 1956, which sheds light on the introduction of the first antipsychotic, chlorpromazine, into clinical practice. We highlight how Gadamer's hermeneutics and Bakhtin's dialogism together offer insights into patient perspectives during this liminal period in the history of psychiatry.

The alignment imperative in curriculum renewal.

RATIONALE: There are perennial calls for MD curricula to reform in order to meet the changing needs of students, patients, and society. And yet, efforts at renewal have also been suggested to have minimal impact on the pedagogy and outcomes of medical education. One reason may be misalignment between the components of the curriculum during design and implementation. The University of Toronto MD program recently renewed its undergraduate preclinical Foundations curriculum. Mindful of the pitfalls of misalignment, the renewal process focused deliberately on alignment between the various components of the curriculum: instructional methods, student assessment, faculty development, and the larger purpose of serving students and society. INNOVATION: Educational evidence was used to drive the alignment process which resulted in three major changes. First, we created a spiral curriculum centered on 72 virtual patient cases designed to integrate content and prepare students for clinical learning. Second, we introduced a novel medical psychiatry component to address a core societal need in mental health. This exposed students early to experiences of complexity, ambiguity, and integrated patient care. Lastly, a shift to assessment for learning and programmatic assessment was designed and implemented concurrently to reinforce the pedagogy of the curriculum. Synchronous faculty development was developed for the new roles required of faculty. CONCLUSIONS: Early program evaluation shows alignment of these curricular components requires ongoing attention and resources in order to be successful. The potential benefits of this alignment are well prepared students who can meet the needs of their patients and society in an increasingly complex health system.

Putting performance in context: the perceived influence of environmental factors on work-based performance.

INTRODUCTION: Context shapes behaviours yet is seldom considered when assessing competence. Our objective was to explore attending physicians' and trainees' perceptions of the Internal Medicine Clinical Teaching Unit (CTU) environment and how they thought contextual factors affected their performance. METHOD: 29 individuals recently completing CTU rotations participated in nine level-specific focus groups (2 with attending physicians, 3 with senior and 2 with junior residents, and 2 with students). Participants were asked to identify environmental factors on the CTU and to describe how these factors influenced their own performance across CanMEDS roles. Discussions were analyzed using constructivist grounded theory. RESULTS: Five major contextual factors were identified: Busyness, Multiple Hats, Other People, Educational Structures, and Hospital Resources and Policies. Busyness emerged as the most important, but all factors had a substantial perceived impact on performance. Participants felt their performance on the Manager and Scholar roles was most affected by environmental factors (mostly negatively, due to decreased efficiency and impact on learning). CONCLUSIONS: In complex workplace environments, numerous factors shape performance. These contextual factors and their impact need to be considered in observations and judgements made about performance in the workplace, as without this understanding conclusions about competency may be flawed.

The Ontario experience of involuntary treatment of pediatric patients with eating disorders.

In this paper, the authors (two clinicians with specialized practices in child and adolescent eating disorders and a lawyer who practices health law in Ontario, Canada) review pertinent aspects of clinical capacity assessment, with elaboration of the specific unique and complex issues which shape that assessment in children and adolescents with eating disorders. The relevant Ontario legislation and institutional framework governing consent and capacity in children and adolescents are reviewed. The literature on involuntary treatment and consent and capacity in patients with eating disorders is reviewed. Specific cases involving child and adolescent patients with eating disorders that have been heard by the Ontario Consent and Capacity Board (OCCB) in the past decade are discussed in order to elucidate the Board's views of consent and capacity in this vulnerable and challenging patient population. Strategies to support clinicians' therapeutic alliances with their patients while both are going through what can be a lengthy and potentially adversarial-seeming legal process are also discussed.

Professing professionalism: are we our own worst enemy? Faculty members' experiences of teaching and evaluating professionalism in medical education at one school.

PURPOSE: To explore clinical faculty members' knowledge and attitudes regarding their teaching and evaluation of professionalism. METHOD: Clinical faculty involved in medical education at University of Toronto Faculty of Medicine were recruited to participate in focus groups between 2006 and 2007 to discuss their knowledge, beliefs, and attitudes about teaching and evaluating professionalism and to determine their views regarding faculty development in this area. Focus groups were transcribed, analyzed, and coded for themes using a grounded theory approach. RESULTS: Five focus groups consisting of 14 faculty members from surgical specialties, psychiatry, anesthesia, and pediatrics were conducted. Grounded theory analysis of the 188 pages of text identified three major themes: Professionalism is not a static concept, a gap exists between faculty members' real and ideal experience of teaching professionalism, and "unprofessionalism" is a persistent problem. Important subthemes included the multiple bases that exist for defining professionalism, how professionalism is learned and taught versus how it should be taught, institutional and faculty tolerance and silence regarding unprofessionalism, stress as a contributor to unprofessionalism, and unprofessionalism arising from personality traits. CONCLUSIONS: All faculty expressed that teaching and evaluating professionalism posed a challenge for them. They identified their own lapses in professionalism and their sense of powerlessness and failure to address these with one another as the single greatest barrier to teaching professionalism, given a perceived dominance of role modeling as a teaching tool. Participants had several recommendations for faculty development and acknowledged a need for culture change in teaching hospitals and university departments.

Disordered eating in Jewish adolescent girls.

OBJECTIVES: To examine the presence and nature of disordered eating attitudes and behaviours among Jewish Canadian adolescents, as compared with non-Jewish Canadian adolescents in an urban community. A secondary goal was to examine whether rates of eating-disordered behaviour differed among the adolescents based on the degree of Jewish religious observance. METHOD: High school students (n = 868) from the Toronto area completed a demographic and religious practice questionnaire together with the Eating Attitudes Test (EAT), a self-report test that discriminated adolescents with syndromal eating disorders from normal adolescents. RESULTS: Jewish females aged 13 to 20 years, but not males, reported significantly more disordered eating behaviours and attitudes, compared with their non-Jewish female counterparts. Twenty-five percent of Jewish females, as compared with 18% of non-Jewish females, scored above the clinical cut-off for the EAT. No differences in vulnerability to disordered eating were found within the group of Jewish females or males related to their degree of religious observance. CONCLUSIONS: Adolescent Jewish females, but not males, appear to be at greater risk for abnormal attitudes and behaviours related to eating, compared with their non-Jewish female peers. While the reasons for this finding are unclear, this study is a step toward improving understanding of the relations between sex, culture, religion, and the development of eating disorders. Culturally sensitive and sex-specific prevention strategies and treatment interventions are indicated.

Developing a feminist-informed model for decision making in the treatment of adolescent eating disorders.

In 1997 the Child and Family Clinic treatment team at Southlake Regional Health Centre (SLRHC) in Newmarket Ontario, Canada created the Eating Disorders Program, which included a day treatment program for adolescents with eating disorders. When first conceived, this day treatment program was the first of its kind in Ontario. The multi-disciplinary team created a feminist-informed model centered on developing joint decision making relationships among team, client, and family through sustained and transparent communication and negotiation. This model for decision making has evolved through careful deliberation and ethical reflection in the planning and provision of care.

Gender-role conflict and suicidal behaviour in adolescent girls.

OBJECTIVE: This study examined whether gender-role conflict influenced the suicidal behaviour of adolescent girls. METHOD: We designed a checklist and used it to perform a chart review. RESULTS: Gender-role conflict was associated with suicidal behaviour in 26.79% of the adolescent girls, and 2.68% of the adolescent boys, that we studied. CONCLUSIONS: Gender-role conflict plays an important role in the suicidal behaviour of girls. At present, there is no published research examining the impact of gender-role conflict on suicidal adolescents.