Medical students' reflections on surgical educators' professionalism: Contextual nuances in the hidden curriculum.

INTRODUCTION: Surgical educators' professional behavior constitutes a hidden curriculum and impacts trainee's professional identity formation. This study explores the nuances of professional behaviors as observed in varying surgical settings. METHODS: 411 Transcripts originated from essays written by MS3 students during their surgical clerkship from 2010 to 2016 were collated. Employing a qualitative research methodology, we conducted a thematic analysis to uncover specific meaning emerging from medical student reflections' on surgical professionalism. RESULTS: In clinics, taking time and protecting patient privacy; in the OR, control over emotion during difficult situations and attention to learners; and in the inpatient setting, showing accountability above normal expected behavior were noted as professional. Similarly, unprofessional behaviors in these contexts paralleled lack of these attributes. CONCLUSIONS: Behaviors observed and the attributes of professionalism in the surgical learning environment have contextual nuances. These variations in professionalism can be utilized in deliberate development of professionalism in surgery.

Ethical Issues Encountered During the Medical Student Surgical Clerkship.

BACKGROUND: Data regarding ethical issues encountered by medical students during the surgical clerkship are sparse. Identification of such issues facilitates development of an ethics curriculum that ensures student preparation for issues most frequently encountered on the surgical rotation. To better understand these issues, we performed content analysis of reflections written by medical students about ethical issues encountered during their surgical clerkship. MATERIALS AND METHODS: All medical students on the surgical clerkship at a university hospital from 4/2017 to 6/2018 submitted a written reflection regarding an ethical issue encountered during the clerkship. Two investigators performed content analysis of each reflection. References to ethical principles (beneficence, nonmaleficence, justice, autonomy) were tabulated. Ethical issues were classified into main categories and subcategories, based on a modified version of a previously published taxonomy. RESULTS: 134 reflections underwent content analysis. Nonmaleficence was the most frequently mentioned ethical principle. 411 specific ethical issues were identified. Ethical issues were distributed across ten main categories: decision-making (28%), communication among health care team members (14%), justice (12%), communication between providers, patients, and families (9%), issues in the operating room (9%), informed consent (9%), professionalism (5%), supervision/student-specific issues (5%), documentation (1%), and miscellaneous/other (8%). We identified two ethical issues infrequently discussed in previous reports: delivery of efficient yet high-quality care and poor communication between services/consultants. CONCLUSIONS: Students encounter diverse ethical issues during their surgical clerkships. Ethical and contextual considerations related to these issues should be incorporated into a preclinical/clinical surgical ethics curriculum to prepare students to understand and engage the challenges they face during the clerkship.

Missed opportunities in the way medical schools evaluate the ethical domain in clerkship rotations.

BACKGROUND: Several lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain. METHODS: The authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students' perspectives. RESULTS: Twenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves. CONCLUSIONS: There are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Informed consent learning: Needs and preferences in medical clerkship environments.

PURPOSE: Limited information exists regarding students' routine educational needs in support of ethics and professionalism practices faced in real clinical practice. As such the authors aimed to explore medical students learning needs and preferences for informed consent and relevant ethical issues in the clerkship environments. MATERIALS AND METHODS: A cross-sectional study using a self-administered, printed survey distributed to final year clinical clerks. RESULTS: 84% completed the survey. Students indicated the need for more attention to all topics related to informed consent (mean = 7.1 on a scale of 0 to 9; ±1.2). Most additional instructional attention was requested for topics raised in discussions with patients concerning the risks, benefits and alternatives to recommended treatments (7.3 ±1.4). The cohort expressed the need for education in the care of vulnerable patients (7.2 ±1.2) with a maximum score for the care of abused children. Women perceived greater need for education concerning informed consent than male respondents (p>0.05). There were significant differences between students who scored high or low on the item "being treated in professional manner" and "endorsement of educational needs for care of adolescents" (p = 0.05). CONCLUSION: There was heightened perception among final year medical students of the need for greater attention to be paid to informed consent education.

Psychosocial issues discovered through reflective group dialogue between medical students.

BACKGROUND: The biopsychosocial model is a comprehensive approach emphasizing holistic medical care. However, medical curricula that incorporate narrative reflective writing and group dynamic discussion of psychosocial issues among patients and their family members in reflective dialogue groups are currently underutilized. The aim of this study was to determine psychosocial issues among patients and their family members through medical students' reflective dialogue groups. METHODS: This study was completed as part of a pediatric clerkship. Fifty medical students were rotated to the department of Pediatrics. They completed a narrative writing assignment concerning patients' psychosocial issues and participated in a reflective group discussion during the rotation. The recordings of the six reflective group sessions were transcribed for thematic analysis. A six-step theme generation process was conducted in the first reading stage of all transcripts by four researchers. Subsequently, initial codes were generated and potential themes sought before possible themes were reviewed and thematic maps generated. Names for each theme were defined and a scholarly report of the analysis was presented through a consensus-based approach. RESULTS: A total of 108 psychosocial issues were coded and categorized as the following six main themes: medical communication, the intricate medical ecological system, role and function of a family, development of medical professionalism, ethical dilemmas, and various patient perspectives from diverse cultural backgrounds. All these themes underlie the complexity of clinical encounters. CONCLUSIONS: Clinical care is an extremely complex interactive ecological network involving human behavior, family, and public health care systems. The discovery of psychosocial problems by medical students as narrators in this study illustrates that medical care should focus not only on illnesses but also patients' psychosocial narratives.

Medical Students Analyze Complex Ethical Issues Observed in Clinical Rotations.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Understanding and addressing missed care in clinical placements - Implications for nursing students and nurse educators.

This paper addresses the issue of substandard care and its effects on healthcare practice. It explores some recent concerns about the problem in nursing, its potential effects on students, how it can be conceptualised and what action needs to be, by both nurses and educators to prevent it. Recent healthcare scandals have tarnished the public image of nursing, and are also likely to influence nursing students' images, expectations and experiences of nursing. While much attention has been paid to the examination of such lapses in care, and potential corrective actions, little attention has been paid to the potential or actual effect on nursing students in practice. While good resources and staffing levels are crucial to ensuring optimal nursing care, developing and encouraging nursing students' awareness of and openness about personal behaviours, reflecting critically on practice reflection and strengthening nurse educators' collaborative links with healthcare practice can all serve to positively influence care deficits.

La ética médica en discusión: análisis de los principales temas sobre ética médica en la práctica clínica tratados en revistas nacionales de medicina y bioética 1998-2013 / Medical ethics argumentation: analysis of main topics about medical ethics in clinical practice dealt in national journals of medicine and bioethics 1998-2013 / A ética médica em discussão: análise dos principais temas de ética médica na prática clínica em revistas nacionais de medicina e bioética 1998-2013

El objetivo de esta investigación es identificar los principales temas de la discusión sobre de ética médica en la práctica clínica en Chile que se suscitan en las revistas de Medicina y Bioética chilenas. Se identificaron 143 artículos que fueron sometidos a un análisis sistemático utilizando técnicas de comparación, codificación y análisis de textos propios del enfoque de la Teoría Fundamentada. Se distinguieron 30 temas en la discusión, en la que predomina el tratamiento de la ética desde la "deontología profesional". También se observan discursos emergentes de una ética que apela a bienes y valores superiores a los deberes profesionales en la búsqueda del bien del paciente, en el marco de un proceso de transformación del contexto en que se ejerce la práctica clínica.

The aim of this investigation is to identify the main topics of the discussion about medical ethics in clinical practice in Chile. 143 articles in Chilean medical and bioethics journals were identified. They were put under a systematic study using comparison, codification and text analysis techniques of the Grounded Theory approach. 30 subjects were identified in the discussion, where the treatment of the ethics from a "professional deontology" predominates. Emergent speeches of an ethics that appeals to goods and values superiors to the professional duties in the search of the good of the patient can be found. The transformation of the context in which the clinical practice takes place is the background of the discussion.

O objetivo desta pesquisa é identificar os principais tópicos da discussão sobre ética médica na prática clínica no Chile, presentes nas revistas nacionais de medicina e bioética. Identificaram-se 143 artigos que foram submetidos a uma análise sistemática, utilizando-se técnicas de comparação, codificação e análise de textos próprios da abordagem da Teoria Fundamentada. Identificaram-se 30 temas na discussão, nos quais predominam o tratamento da ética a partir da "deontologia profissional". Também se observam discursos emergentes de uma ética que apela aos bens e valores superiores aos deveres profissionais na busca pelo bem do paciente, no âmbito de um processo de transformação do contexto em que é exercida a prática clínica.

Gift-Giving in the Podiatric Medical Student-Patient Relationship.

We sought to explore the relationship between the podiatric medical student and the patient as it relates to the act of gift-giving as a sign of gratefulness for the services provided. This article presents the clinical case of a man who visited a podiatric medical student because of pain in his feet and subsequently presented the student with several gifts. Philanthropy, empathy, a positive attitude, treatment instructions, and the time devoted to the patient are some of the reasons why patients offer gifts to podiatric medical students. The relationship between the podiatric medical student and the patient and the act of gift-giving by patients are of ethical concern.

Caring to Care: Applying Noddings' Philosophy to Medical Education.

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.

Offshore Medical Schools Are Buying Clinical Clerkships in U.S. Hospitals: The Problem and Potential Solutions.

U.S. medical education faces a threat from for-profit Caribbean medical schools which purchase clinical rotation slots for their students at U.S. hospitals. These offshore schools are monetizing a system that was previously characterized as a duty-the duty of the current generation of physicians to educate their successors. Offshore schools purchase clinical rotation slots using funds largely derived from federally subsidized student loans. This leads to pressure on U.S. schools to pay for clinical clerkships and is forcing some of them to find new clinical training sites.For-profit Caribbean schools largely escape the type of scrutiny that U.S. schools face from U.S. national accreditation organizations. They also enroll large classes of students with lower undergraduate GPAs and Medical College Admission Test scores than those of students at U.S. medical schools; their students take and pass Step 1 of the United States Medical Licensing Examination at a substantially lower rate than that of U.S. medical students; and their students match for residencies at a fraction of the rate of U.S. medical school graduates.Among the potential solutions proposed by the authors are passing laws to hold for-profit Caribbean schools to standards for board passage rates, placing restrictions on federal student loans, monitoring attrition rates, and denying offshore schools access to U.S. clinical training sites unless they meet accreditation standards equivalent to those of U.S. medical schools.

Designing an ethics curriculum to support global health experiences in surgery.

BACKGROUND: The field of global health is rapidly expanding in many medical centers across the US. As a result, medical students have increasing opportunities to incorporate global health experiences (GHEs) into their medical education. Ethics is a critical component of global health curricula, yet little literature exists to direct the further development of didactic training. Therefore, we sought to define ethical encounters experienced by medical students participating in short-term surgical GHEs and create a framework for the design of ethics curriculum specific to global surgery. MATERIALS AND METHODS: Emory University Departments of Surgery, Urology, and Anesthesia, in partnership with the non-profit organization Project Medishare, have taken annual humanitarian surgical trips to Hinche, Haiti. All medical students returning from the trips in 2011 and 2012 received a 35-question survey to assess demographic data, extent of prior ethics education, frequency of exposure and situational confidence to ethical subject matter, as well as ethical conflicts involved in surgical GHEs. The same comparative data were also collected for domestic clinical clerkships. RESULTS: Seventeen out of 21 medical students completed the survey. Nearly all (88.3%) students had previous formal ethics training as an undergraduate or in medical school. Ethical issues were commonly encountered during domestic clinical encounters and volunteerism. However, students reported enhanced exposure to the professional obligation of surgeons (P = 0.025) and truth-telling/surgeon-patient relationships (P = 0.044) during surgical volunteerism. Despite increased exposure, situational confidence did not change. CONCLUSIONS: Ethical issues are commonly confronted during GHEs in surgery and differ from domestic clinical encounters. Healthcare ethics curriculum should be designed to meet the needs of medical students involved in global health.

Physician assistant program directors' attitudes, practices, and plans regarding financial compensation to clinical sites.

PURPOSE: Some physician assistant (PA) program directors believe paying clinicians and administrators for clinical sites is fair and necessary, while others regard such practices as undermining traditional altruistic motivations for precepting. The purpose of this study was to assess PA program directors' attitudes on this topic and describe current practices and future plans regarding compensation to clinical sites. METHODS: A cross-sectional descriptive survey was sent to directors of PA programs with continuing and provisional accreditation status in 2012. RESULTS: Seventy-eight (48%) of the 163 program directors surveyed participated in the study. Although most respondents indicated that paying for clinical sites was not an acceptable practice, almost half believed it would. be acceptable if there were standards and definitions for equitable and fair payments. Despite the finding that most respondents' programs do not pay for clinical sites, nearly half anticipate their programs will be paying for clinical sites in three years, and the cost of such payments will be passed on to students in the form of increased tuition or separate fees. Many indicated a concern that paying for clinical sites may result in monopolies and bidding wars. CONCLUSION: While paying clinical sites may be effective for recruitment and retention of clinical sites, most program directors are concerned about the expanded role economics will have for their program. Agreed-upon standards and definitions for fair and equitable payment practices may alleviate some of these concerns. However, the potential effects on students and programs identified in this study necessitate additional research to fully assess what implications this may have on PA education and the profession.

Ethical dilemmas in clerkship rotations.

A sound clinical education should include the opportunity for medical students to engage in a spirited and informed discussion with faculty about the ethical challenges they will undoubtedly face. Unfortunately, in many medical schools today this goal is thwarted by many factors, including denial that a problem exists, relentless system overload, unprofessional behavior, breakdown in communication, and inertia. What is worse is that this problem is not new, and the fallout is not insignificant. Another potential contributing factor is burnout, which is well documented in a high percentage of medical students, residents, and faculty, and two of its most serious consequences are patient dissatisfaction and medical error.The authors draw on hundreds of student reflections on ethical dilemmas submitted during classroom exercises to examine persistent themes. They posit that classroom and didactic teaching is not enough to enable students to face ethical dilemmas. The authors call for a major culture change in medical education: "buy in" from top administration, especially the dean (and associate/assistant deans), chairs of all departments, and clerkship and residency training directors; the appointing of an ombudsperson and/or ethicist to oversee and resolve issues as they arise; instructional workshops and materials to enhance and impart skills for all teachers; remediation or retiring of errant faculty; and ongoing research and dialogue between and among medical centers about novel solutions.

Should trainee doctors use the developing world to gain clinical experience? The annual Varsity Medical Debate - London, Friday 20th January, 2012.

The 2012 Varsity Medical Debate between Oxford University and Cambridge University provided a stage for representatives from these famous institutions to debate the motion "This house believes that trainee doctors should be able to use the developing world to gain clinical experience." This article brings together many of the arguments put forward during the debate, centring around three major points of contention: the potential intrinsic wrong of 'using' patients in developing countries; the effects on the elective participant; and the effects on the host community. The article goes on to critically appraise overseas elective programmes, offering a number of solutions that would help optimise their effectiveness in the developing world.

Exploring the hidden curriculum: a qualitative analysis of clerks' reflections on professionalism in surgical clerkship.

BACKGROUND: Professionalism is an important part of the hidden curriculum that is gaining attention in surgical education. McMaster University, Hamilton, Ontario, Canada, has introduced a small group discussion model using critical incident reports (CIRs) to elicit students' reflections on ethical, communication, and professionalism challenges during surgical clerkship. We described the themes identified by surgical clerks in their CIRs. METHODS: Using thematic analysis, 4 investigators coded 64 CIRs iteratively until conceptual saturation. Rigor and validity were ensured throughout the process. Data were further explored to compare the CIRs of junior and senior clerks. RESULTS: Twenty-seven themes and 4 relationship domains emerged: the clerk's relationship to patients, the health care team, the health care system, and self. Challenges with communication, the consent process, and breaking bad news were most commonly cited. Theme frequencies differed between junior and senior clerks. CONCLUSIONS: Small group discussions of critical incident reports allow surgical clerks to reflect on their developing professional relationships. The themes that have been identified can be used to guide professionalism education and uncover the hidden curriculum.

Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships.

BACKGROUND: Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. METHOD: We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. RESULTS: A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). CONCLUSIONS: Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying "ethical" issues, "professional" issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives.