How do medical students' expectations shape their experiences of well-being programmes?

INTRODUCTION: Medical schools have a duty of care to support their students' health and well-being. Student support studies have tended to focus on outcomes in respect of effectiveness and satisfaction. In contrast, little is known about how student expectations of support may shape their experiences and engagement with support mechanisms, as well as the relationships students have with those offering support (including the institution itself). To address this gap in knowledge, we explore how medical students' expectations of student support systems shape, and are shaped by, institutional rules and processes. METHODS: We employed a qualitative case study approach using an institutional ethnography informed methodology. Our context was a medical school that provides a well-advertised, formal institutional support system where students are assigned a personal tutor. Data collection included interviews with medical students (n = 13) plus document analysis (public facing artefacts and internal policies/guidelines related to the support system). We applied the lens of psychological contract theory to guide abductive analysis of interview and text data. RESULTS: Students expected a strong support system to be provided by the medical school and the personal tutors. However, their experiences did not always align with their expectations. Some felt excluded by the system while others regarded the relationship with their personal tutor as more transactional than relational. Where their expectations were unmet, students responded by reducing their engagement with the formal support system and creating their own peer-support network that supplemented existing formal support. DISCUSSION: Student expectations matter in shaping their experiences of support systems. Where expectations are unmet, students may disengage and/or find alternatives. This may be easier for some students compared with others. More understanding of the relationship between expectations and engagement with support can inform the development of institutional support structures that meet the needs of all students across time.

Power failure; an uncomfortable teaching initiative?

BACKGROUND: Introducing medical students to the concept of Cultural Humility, we devised a teaching initiative for students to consider how power manifests through the use of language in clinical communication, with a focus on General Practice. Cultural Humility is a pedagogical framework, introduced by Tervalon and Murray-Garcia, to address what they consider as the limitations of the Cultural Competence model. APPROACH: Our teaching initiative specifically focused on power in clinical communication, both oral consultations and written notes. The session was delivered to third-year medical students during their first 'clinical' year, where they regularly witness and are involved in clinical communication across primary and secondary care placements. Ethical approval was in place to analyse students' reflections on the session. EVALUATION: Students who attended engaged well. They evaluated the session positively as increasing their awareness of the power of clinical language in negatively stereotyping and dehumanising patients. They demonstrated Cultural Humility in their reflections of the unintentional harm of clinical language commonly used for the doctor-patient relationship. However, most striking for us, and where our learning as educators lies, was the low attendance at the session, despite our attempts to underline clinical relevance and importance for development as future doctors. IMPLICATIONS: This article offers a framework for educators interested in Cultural Humility. The implications of this initiative are how (or how not) to develop and deliver training in this space. More consideration is required as educators, including around our own language, as to how to engage students to think around the complex topic of power.

Navigating Confidentiality Dilemmas in Student Support: An Institutional Ethnography Informed Study.

Introduction: School-level student support programmes provide students with pastoral care and support for academic, wellbeing and other issues often via a personal tutor (PT). PT work is a balancing act between respecting the confidential information divulged by students and doing what is expected in terms of accountability and duty of care. We aimed to explore how tutors manage this tension, with the aim of advancing understanding of student support programmes. Methods: This qualitative study was informed by an Institutional Ethnography approach. We conducted 11 semi-structured interviews with PTs from one medical school in Singapore. We considered how they worked in relation to relevant national and institutional-level policy documents and reporting guidelines. Data collection and analysis were iterative. Results: We crafted two composite accounts to illustrate the dilemmas faced by PTs. The first depicts a PT who supports student confidentiality in the same way as doctor-patient confidentiality. The second account is a PT who adopted a more mentoring approach. Both tutors faced confidentiality challenges, using different strategies to "work around" and balance tensions between accountability and maintaining trust. PTs were torn between school and student expectations. Discussion: Fostering trust in the tutor-student relationship is a priority for tutors but tensions between confidentiality, accountability and governance sometimes make it difficult for tutors to reconcile with doing what they think is best for the student. A more nuanced understanding of the concept of confidentiality may help support PTs and ultimately students.

Learning to navigate uncertainty in primary care: a scoping literature review.

BACKGROUND: Clinical practice occurs in the context of uncertainty. Primary care is a clinical environment that accepts and works with uncertainty differently from secondary care. Recent literature reviews have contributed to understanding how clinical uncertainty is taught in educational settings and navigated in secondary care, and, to a lesser extent, by experienced GPs. We do not know how medical students and doctors in training learn to navigate uncertainty in primary care. AIM: To explore what is known about primary care as an opportunity for learning to navigate uncertainty. DESIGN & SETTING: Scoping review of articles written in English. METHOD: Using a scoping review methodology, Embase, MEDLINE, and Web of Science databases were searched, with additional articles obtained through citation searching. Studies were included in this review if they: (a) were based within populations of medical students and/or doctors in training; and (b) considered clinical uncertainty or ambiguity in primary care or a simulated primary care setting. Study findings were analysed thematically. RESULTS: Thirty-six studies were included from which the following three major themes were developed: uncertainty contributes to professional identity formation (PIF); adaptive responses; and maladaptive behaviours. Relational and social factors that influence PIF were identified. Adaptive responses included adjusting epistemic expectations and shared decision making (SDM). CONCLUSION: Educators can play a key role in helping learners navigate uncertainty through socialisation, discussing primary care epistemology, recognising maladaptive behaviours, and fostering a culture of constructive responses to uncertainty.

Is there ever a single best answer (SBA): assessment driving certainty in the uncertain world of GP?

Uncertainty is inherent in all areas of medical practice, not least in primary care, which is defined by its acceptance of uncertainty and complexity. Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical assessments; however clinical practice, particularly in primary care, challenges the supposition that a single best answer exists for all clinical encounters and dilemmas. In this article, we seek to highlight several aspects of the relationship between this assessment format and clinical uncertainty by considering its influence on medical students' views of uncertainty in the contexts of their medical education, personal epistemology, and clinical expectations.

Towards accountability-centred practices: governance in OSCEs subordinating patient and practitioner clinical experience.

New public management ideals and standards have become increasingly adhered to in health professions education; this is particularly apparent in high-stakes assessment, as a gateway to practice. Using an Institutional Ethnographic approach, we looked at the work involved in running high-stakes Objective Structured Clinical Exams (OSCEs) throughout an academic year including use of observations, interviews and textual analysis. In our results, we describe three types of 'work'-standardising work, defensibility work and accountability work-summarising these in the discussion as an Accountability Circuit, which shows the organising role of texts on people's work processes. We show how this form of governance mandates a shift towards accountability-centred practices, away from practices which are person-centred; this lens on accountability-centring during high-stakes assessments invites critique of the often-unquestioned emphasis of new public management in health professions education.

Essential workers? An institutional ethnographic lens on pandemic GP placements.

BACKGROUND: Clinical placements for medical students in the United Kingdom (UK) came to an abrupt halt in March 2020. The rapidly evolving Covid19 pandemic created specific challenges for educators, balancing safety concerns for patients, students and healthcare staff alongside the imperative to continue to train future clinicians. Organisations such as the Medical Schools Council (MSC) published guidance to help plan return of students to clinical placements. This study aimed to examine how GP education leads made decisions around students returning to clinical placements for the 20/21 academic year. METHOD: Data collection and analysis was informed by an Institutional Ethnographic approach. Five GP education leads from medical schools throughout the UK were interviewed (over MS TEAMS™). Interviews focused on the work the participants did to plan students' return to clinical placements and how they used texts to inform this work. Analysis focused on the interplay between the interview and textual data. RESULTS AND DISCUSSION: GP education leads actively used MSC guidance which confirmed students to be 'essential workers', an unquestioned and unquestionable phrase at the time. This permitted students to return to clinical placements by affording the GP education leads authority to ask or persuade GP tutors to accept them. Furthermore, by describing teaching as 'essential work' in its own right in the guidance, this extended what the GP tutors came to expect to do as 'essential workers' themselves. CONCLUSION: GP education leads activated authoritarian phrases such as 'essential workers' and 'essential work' contained within MSC guidance to direct students' return to clinical placements in GP settings.

(L)earning: Exploring the value of paid roles for medical students.

BACKGROUND: The Medical Student Technician (MST) role is a paid position established in Northern Ireland in 2020. The Experience-Based Learning (ExBL) model is a contemporary medical education pedagogy advocating supported participation to develop capabilities important for doctors-to-be. In this study, we used the ExBL model to explore the experiences of MSTs and how the role contributed to students' professional development and preparedness for practice. METHODS: A convenience sampling strategy was used to recruit a total of 17 MSTs in three focus groups. Semi-structured interviews were transcribed verbatim and analysed using the ExBL model as a framework. Transcripts were independently analysed and coded by two investigators and discrepancies resolved with the remaining investigators. RESULTS: The MST experiences reflected the various components of the ExBL model. Students valued earning a salary; however, what students earned transcended the financial reward alone. This professional role enabled students to meaningfully contribute to patient care and have authentic interactions with patients and staff. This fostered a sense of feeling valued and increased self-efficacy amongst MSTs, helping them acquire various practical, intellectual and affective capabilities and subsequently demonstrate an increased confidence in their identities as future doctors. CONCLUSION: Paid clinical roles for medical students could present useful adjuncts to traditional clinical placements, benefiting both students and potentially healthcare systems. The practice-based learning experiences described appear to be underpinned by a novel social context where students can add value, be and feel valued and gain valuable capabilities that better prepare them for starting work as a doctor.

Conscious engagement within patients' and simulated participants' personal space: medical students' perspective.

BACKGROUND: #MeToo prompted a shift in acceptable societal norms, sparking global recognition of the complexities of entering another's personal space. Physical examinations are an integral part of medicine yet have the capacity to encroach upon patient's personal space, whether in simulated or clinical environments. Examinations may be misconstrued as inappropriate advances, with negative effects for both patient and doctor. Medical educators must consider how they teach students to approach this complex task. This study aimed to gain insight into the lived experiences of medical students when working within patient's personal space. This builds on previous research from the perspective of simulated participants. METHOD: A hermeneutic phenomenology approach was used to explore lived experiences of working within patient's personal space. Data was collected from seven medical students through semi-structured interviews and thematically analysed using template analysis. RESULTS: The analysis yielded four main themes: (1) transitioning into a privileged position; (2) negative role modelling: emphasising the physical; (3) consent: a dynamic and fragile state; and (4) a simple act or a complex performance? DISCUSSION: This study provides a unique insight into the lived experiences of medical students when working within a patient's personal space. The physical examination is a complex process; the experiences of medical students can shape learning on crossing boundaries. Medical educators need to reflect this complexity in teaching, mirroring societal interest around the boundaries of consent. Students need a pedagogical space to develop these interpersonal skills, to prevent early adoption of the clinical gaze, and to create more consciously engaged doctors for the future.

Revised paper ASIM-D-21-00055R1: "Consulting properly rather than acting": advocating for real patient involvement in summative OSCEs.

BACKGROUND: In this "Advancing simulation practice" article, we offer an expose of the involvement of real patients in Objective Structured Clinical Examinations (OSCEs), inviting educators who traditionally involve solely SPs in their summative OSCEs to consider the practice. The need for standardisation in summative assessments can make educators understandably wary to try this, even if the rhetoric to involve real patients is accepted. We offer this as an instance of the tussle between standardisation and validity experienced throughout health professions education. MAIN TEXT: We offer our experience and empirical evidence of this simulation practice, based on an institutional ethnographic examination of the involvement of real patients in summative OSCEs from an undergraduate medical school in the UK. Our critique demonstrates the merits of this approach as an assessment environment closer to the real clinical environments where these soon-to-be doctors interact in a more authentic way with real patients and their illness experiences. We balance this against the extra work required for all involved and suggest the biggest challenge is in the reorientation work required for both Faculty and students who are institutionalised to expect standardisation above all in assessment. CONCLUSION: We advocate for involving real patients in summative OSCEs and hope that readers may feel compelled and empowered to foster this shift in mindset required to introduce this practice into their assessments.

Why institutional ethnography? Why now? Institutional ethnography in health professions education.

This 'A Qualitative Space' article takes a critical look at Dorothy Smith's approach to inquiry known as institutional ethnography and its potentiality in contemporary health professions education research. We delve into institutional ethnography's philosophical underpinnings, setting out the ontological shift that the researcher needs to make within this critical feminist approach. We use examples of research into frontline healthcare, into the health work of patients and into education to allow the reader to consider what an institutional ethnography research project might offer. We lay out our vision for potential growth for institutional ethnography research within the health professions education field and explain why we see this as the opportune moment to adopt institutional ethnography to meet some of the challenges facing health professions education in a way that offers informed change.

Blurred boundaries: sexuality and power in standardised patients' negotiations of the physical examination.

BACKGROUND: Working with standardised or simulated patients (SPs) is now commonplace in Simulated Learning Environments. Embracing the fact that they are not a homogenous group, some literature suggests expansion of learning with SPs in health professional education by foregrounding their personal experiences. Intimate examination teaching, whether with or without the help of SPs, is protected by a particular degree of ceremony given the degree of potential vulnerability. However, other examinations may be equally intrusive for example the close proximity of an eye examination or a chest examination in a female patient. In this study, we looked at SPs' experiences of boundary crossing in any examinations, sensitised by Foucault's concept of the clinical gaze. We wished to problematise power relations that construct and subject SPs as clinical tools within simulation-based education. METHODS: We collected data from 22 SPs, through five focus groups. Analysis was an iterative process, using thematic analysis. Data collection and reflexive analysis continued iteratively until concepts were fully developed and all theoretical directions explored. RESULTS: Students and SPs construct simulated teaching consultations by negotiating the unequal distribution of power between them. The SPs themselves discussed how they, perhaps unknowingly, acted in accordance with the discourse of the clinical gaze. However, SPs became disempowered when students deviated from the negotiated terms of consent and they used their agency to resist this. The SPs used strong sexual metaphors to express the subjugation they experienced, as discourses of sexuality and gender played out in the Simulated Learning Environment. CONCLUSION: We demonstrate that power dynamics and the clinical gaze can have important consequences within the Simulated Learning Environment. Every physical examination can be potentially 'intimate' and can therefore be underpinned by discourses of sexuality and gendered undertones. In partnership with SPs, simulation-based education should create a teaching space that no longer fosters the discourse of the clinical gaze but facilitates students to learn to reflectively navigate, in the moment, the fine line between touching patients versus touching loved ones, and the blurred boundaries that exist in the gulf between sexual contact and benevolent touch.