"I felt like a little kind of jolt of energy in my chest": embodiment in learning in continuing professional development for general practitioners.

Learning in medical education encompasses a broad spectrum of learning theories, and an embodiment perspective has recently begun to emerge in continuing professional development (CPD) for health professionals. However, empirical research into the experience of embodiment in learning in CPD is sparse, particularly in the practice of general medicine. In this study, we aimed to explore general practitioners' (GPs') learning experiences during CPD from an embodiment perspective, studying the appearance of elements of embodiment-the body, actions, emotions, cognition, and interactions with the surroundings and others-to build an explanatory structure of embodiment in learning. We drew on the concepts of embodied affectivity and mutual incorporation to frame our understanding of embodiment. Four Danish and three Canadian GPs were interviewed to gain insight into specific learning experiences; the interviews and the analysis were inspired by micro-phenomenology, augmented with a complex adaptive systems approach. We constructed an explanatory structure of learning with two entrance points (disharmony and mundanity), an eight-component learning phase, and an ending phase with two exit points (harmony and continuing imbalance). All components of the learning phase-community, pride, validation, rehearsal, do-ability, mind-space, ambiance, and preparing for the future-shared features of embodied affectivity and mutual incorporation and interacted in multi-directional and non-linear ways. We discuss integrating the embodiment perspective into existing learning theories and argue that CPD for GPs would benefit from doing so.

Data driven or data informed? How general practitioners use data to evaluate their own and colleagues' clinical work in clusters.

In contemporary policy discourses, data are presented as key assets for improving health-care quality: policymakers want health care to become 'data driven'. In this article, we focus on a particular example of this ambition, namely a new Danish national quality development program for general practitioners (GPs) where doctors are placed in so-called 'clusters'. In these clusters, GPs are obliged to assess their own and colleagues' clinical quality with data derived from their own clinics-using comparisons, averages and benchmarks. Based on semi-structured interviews with Danish GPs and drawing on Science and Technology Studies, we explore how GPs understand these data, and what makes them trust-or question-a data analysis. The GPs describe how they change clinical practices based on these discussions of data. So, when and how do data for quality assurance come to influence their perceptions of quality? By exploring these issues, we carve out a role for a sociological engagement with evidence in everyday medical practices. In conclusion, we suggest a need to move from the aim of being data driven to one of being data informed.

General practitioners' role in safeguarding patients with dementia in their use of dietary supplements. A qualitative study.

OBJECTIVE: The use of dietary supplements (DS) may cause harm through direct and indirect effects. Patients with dementia may be particularly vulnerable. This study aims to explore general practitioners' (GPs') experiences with DS use by these patients, the GPs perceived responsibilities, obstacles in taking on this responsibility, their attitudes toward DS, and suggestions for improvements to safeguard the use of DS in this patient group. DESIGN: Qualitative individual interview study conducted February - December 2019. Data were analysed using systematic text condensation. SETTING: Primary healthcare clinics in Norway. SUBJECTS: Fourteen Norwegian GPs. FINDINGS: None of the informants were dismissive of patients using DS. They were aware of the possible direct risks and had observed them in patients. Most GPs showed little awareness of potential indirect risks to patients with dementia who use DS. They acknowledged the need for caretaking of these patients. Although there were differences in practice styles, most of the GPs wished to help their patients safeguarding DS use but found it difficult due to the lack of quality assurance of product information. Furthermore, there were no effective ways for the GPs to document DS use in the patients' records. Several suggestions for improvement were given by the GPs, such as increased attention from GPs, inclusion of DS in the prescription software, and stricter regulatory systems for DS from the authorities. CONCLUSION: The GPs had initially little awareness of this safety risk, but there were differences in practice style and attitudes towards DS. The GPs did not perceive themselves as main responsible for safe use of DS in patient with dementia. The most important reason to disclaim responsibility was lack of information about the products. One suggestion for improvement was better integration of DS in patients' medical record.

Currently, little is known about general practitioners (GPs) caretaking of patients with dementia who use dietary supplements (DS). Our study showed that:The GPs in this study showed little awareness of the potential safety risk that DS use may represent for patients with dementia.Several obstacles in the treatment setting and in the regulation of DS make it difficult for the GPs to assume full responsibility for patients with dementia who use DS.Lack of evidence about DS safety and effect adds to professional uncertainty and may cause frustration or reluctance to address the issue.

Would you like to be a general practitioner? Baseline findings of a longitudinal survey among Danish medical trainees.

BACKGROUND: Recruiting and securing primary care physician workforce has been the center of international attention for decades. In Denmark, the number of general practitioners has decreased by 8.5% since 2013. However, a rising population age and increasing prevalence of chronic diseases and multimorbidity place an even greater future need for general practitioners in Denmark. The choice of general practice as specialty has been associated with a range of both intrinsic and extrinsic factors, however, few studies have examined the recruitment potential that lies within medical trainees' who are undecided about general practice specialization. The aim of this study was, therefore, to explore how medical trainees who are undecided about general practice specialization (GP-positive/undecided) differ from medical trainees who are either committed (GP-committed) or not committed to a general practice career (GP-non-committed) regarding factors related to future work life. METHODS: The present study concerns baseline findings from a longitudinal survey study. An online questionnaire was e-mailed to a national cohort of medical trainees during their transition from under- to postgraduate education. The associations between orientations towards general practice specialization and work-related factors and potential influencing factors, respectively, were analyzed using uni- and multivariable modified Poisson regression models. RESULTS: Of 1,188 invited participants, 461 filled out key study variables concerning specialty preferences and rejections, corresponding to a response rate of 38.8%. We found significant positive associations between GP-positive/undecided orientation and valuing a good work/life balance and the opportunity to organize own working hours when compared to GP-non-committed respondents. Compared to the GP-committed orientations, the GP-positive/undecided orientation was associated with a positive attitude towards technology, working shift hours, and an openness towards several career paths. Across all orientations, undergraduate exposure to the specialties was found to be highly influential on the specialty preferences. CONCLUSION: GP-positive/undecided medical trainees value autonomy over their working hours more than the GP-non-committed, but less than the GP-committed. However, the GP-positive/undecided respondents present more openness to different career opportunities and the use of technology in daily work. We suggest using this knowledge in the planning of recruitment strategies aiming to increase interest in general practice specialization.

How much time do emergency department physicians spend on medication-related tasks? A time- and-motion study.

BACKGROUND: Medication-related problems are an important cause of emergency department (ED) visits, and medication errors are reported in up to 60% of ED patients. Procedures such as medication reconciliation and medication review can identify and prevent medication-related problems and medication errors. However, this work is often time-consuming. In EDs without pharmacists, medication reconciliation is the physician's responsibility, in addition to the primary assignments of examining and diagnosing the patient. The aim of this study was to identify how much time ED physicians spend on medication-related tasks when no pharmacists are present in the EDs. METHODS: An observational time-and-motion study of physicians in three EDs in Northern Norway was conducted using Work Observation Method by Activity Timing (WOMBAT) to collect and time-stamp data. Observations were conducted in predefined two-hour observation sessions with a 1:1 relationship between observer and participant, during Monday to Friday between 8 am and 8 pm, from November 2020 to October 2021. RESULTS: In total, 386 h of observations were collected during 225 observation sessions. A total of 8.7% of the physicians' work time was spent on medication-related tasks, of which most time was spent on oral communication about medications with other physicians (3.0%) and medication-related documentation (3.2%). Physicians spent 2.2 min per hour on medication reconciliation tasks, which includes retrieving medication-related information directly from the patient, reading/retrieving written medication-related information, and medication-related documentation. Physicians spent 85.6% of the observed time on non-medication-related clinical or administrative tasks, and the remaining time was spent standby or moving between tasks. CONCLUSION: In three Norwegian EDs, physicians spent 8.7% of their work time on medication-related tasks, and 85.6% on other clinical or administrative tasks. Physicians spent 2.2 min per hour on tasks related to medication reconciliation. We worry that patient safety related tasks in the EDs receive little attention. Allocating dedicated resources like pharmacists to contribute with medication-related tasks could benefit both physicians and patients.

Medical trainees' speciality considerations at their transition from under- to postgraduate education: a descriptive, cross-sectional study.

PURPOSE: This paper aims to provide knowledge on medical trainees' considerations about specialisation as they move from undergraduate to postgraduate medical education; especially their interest in general practice compared to other specialities. METHOD: We developed and content-validated a questionnaire to examine medical trainees' speciality considerations and conducted a descriptive, cross-sectional study. All medical trainees initiating their internship in Denmark in 2022 (N = 1,188) were invited to participate in the study. Medical specialities were categorised as hospital service specialities, internal medicine specialities, primary care, psychiatry specialities and surgery and emergency specialities. Descriptive statistics were used to describe the cohort and examine the participants' speciality considerations by assigning them to one of the following three orientations: committed, undecided or non-committed to a speciality. RESULTS: The response rate was 38.8% (n = 461), and participants' mean age was 27.4 years with a majority of females (68.1%). Nearly 25% of the participants had general practice as speciality preference, and only 13.9% had excluded general practice for future specialisation. Overall, around half of the participants had general practice as a first, second or third preference for specialisation. CONCLUSION: Danish medical trainees show considerable interest in general practice at the time of their transition from undergraduate to postgraduate education. However, to meet future demands on the primary care, further recruitment of general practitioners is still needed. This knowledge of the specialities' recruitment potential will likely be of interest to medical educators and healthcare planners alike.

Migration health research in Norway: a scoping review.

Aims: To provide an overview of published research on migration and health conducted in Norway and identify gaps in the research field. Methods: Applying a scoping review methodology, we searched Medline for articles on migration health in Norway published between 2008 and 2020, and assessed them according to research topic, methodology, user-involvement and characteristics of the populations studied (country or area of origin, type of migrant/immigrant status). Results: Of the 707 articles retrieved, 303 met the inclusion criteria. Most studies (77%) were within the clinical disciplines reproductive health, mental health, infectious diseases and cardiovascular diseases, or on socio-cultural aspects and the use of healthcare services. One third of the papers (36%) pulled participants from various geographic backgrounds together or did not specify the geographic background. Among those who did so, participants were mostly from The Middle East, South and Southeast Asia and sub-Saharan Africa. Only 14% of the articles specified the type of migrant/immigrant status and those included refugees, asylum seekers and undocumented migrants. A total of 80% of the papers used quantitative methods, of which 15 described an intervention; 15 papers (5%) described different types of user-involvement. Conclusions: Our findings suggest gaps in research related to migrant subgroups, such as those from Eastern-Europe and labour and family reunification migrants. Future studies should further investigate the self-identified health needs of different migrant groups, and might also benefit from a methodological shift towards more intervention studies and participatory approaches.

Completeness of medication information in admission notes from emergency departments.

BACKGROUND: Medication lists prepared in the emergency department (ED) form the basis for diagnosing and treating patients during hospitalization. Since incomplete medication information may lead to patient harm, it is crucial to obtain a correct and complete medication list at hospital admission. In this cross-sectional retrospective study we wanted to explore medication information completeness in admission notes from Norwegian EDs and investigate which factors were associated with level of completeness. METHODS: Medication information was assessed for completeness by applying five evaluation criteria; generic name, formulation, dose, frequency, and indication for use. A medication completeness score in percent was calculated per medication, per admission note and per criterion. Quantile regression analysis was applied to investigate which variables were associated with medication information completeness. RESULTS: Admission notes for patients admitted between October 2018 and September 2019 and using at least one medication were included. A total of 1,080 admission notes, containing 8,604 medication orders, were assessed. The individual medications had a mean medication completeness score of 88.1% (SD 16.4), while admission notes had a mean medication completeness score of 86.3% (SD 16.2). Over 90% of all individual medications had information about generic name, formulation, dose and frequency stated, while indication for use was only present in 60%. The use of an electronic tool to prepare medication information had a significantly strong positive association with completeness. Hospital visit within the last 30 days, the patient's living situation, number of medications in use, and which hospital the patient was admitted to, were also associated with information completeness. CONCLUSIONS: Medication information completeness in admission notes was high, but potential for improvement regarding documentation of indication for use was identified. Applying an electronic tool when preparing admission notes in EDs seems crucial to safeguard completeness of medication information.

'Illuminating determinants of implementation of non-dispensing pharmacist services in home care: a qualitative interview study'.

OBJECTIVES: Medication errors are leading causes of hospitalization and death in western countries and WHO encourages health care providers to implement non-dispensing pharmacist services in primary care to improve medication work. However, these services struggle to provide any impact on clinical outcomes. We wanted to explore health care professionals' views on medication work to illuminate determinants of the implementation success. The research was designed to inform and adapt implementation strategies for non-dispensing pharmacist services. DESIGN: Semi-structured interview study with nine healthcare professionals. SETTING: Four Norwegian home care wards. SUBJECTS: Nine healthcare professionals working at different wards within one home care unit. MAIN OUTCOME MEASURES: Determinants of implementation outcomes. RESULTS: Contextual determinants of the implementation process were mainly related to characteristics of the setting such as poorly designed information systems, work overload, and chaotic work environments. The identified barriers question the innovation's appropriateness related to the setting's needs but also provide possibilities for tailoring pharmacist services to local medication work issues. The observable positive effects and the perceived advantage of the pharmacist services are likely to facilitate the implementation process. CONCLUSION: Our study provided information on contextual elements that influence the implementation process of non-dispensing pharmacist services. Awareness of these factors can help develop strategies to help the organization succeed in in achieving program outcomes.

The results in this study illuminate barriers and facilitators to the implementation of pharmacist services in a home care setting.Existing medication work methods and poor information handover systems are likely to counteract outcomes of the pharmacist services and inflict unfavorable conditions for implementation.Healthcare professionals' perception of increased medication work support and confidence in pharmacist skills suggest innovation acceptability and serve as indicators of implementation success. The identified barriers to improving medication work provide opportunities to develop tailored strategies to enhance the implementation of non-dispensing pharmacist services.

When the Patient is Absent in Patient-Centered Communication Training: A Discursive Analysis of How Medical Students Learn to Interact with Patients.

Phenomenon: Patient-centered communication is an ideal for undergraduate medical education and has been for decades. However, medical students often find the patient-centered approach challenging. The present study finds a possible discordance between formal intentions of a medical curriculum and the corresponding learning environment. The objective of our study was to explore how medical curriculum resonates with the purpose of patient-centered medicine, including how a possible dynamic may have helped maintain this discordance in undergraduate medical education. Approach: The study took a qualitative approach exploring the medical curriculum via a structured communication course. The educational context for the course was considered a discursive environment, partially constructed through documents. The concept of textual agency was used to analyze curriculum and course documents. This was to explore how competencies were presented in the medical curriculum and course descriptions and how they were translated through the practices of the communication course. Inductive thematic analysis was used to analyze observations made during the course. Findings: Our analysis suggested that the medical curriculum content and structure still emphasize bio-medical disciplines and knowledge domains in students learning. This connected well with the socialization of medical students toward the role as medical experts whose primary task is to provide information, while patients are defined as passive subjects, who received information. The course description also operationalized complexities of patient-centered communication to a measurable, instrumental structure of skills. This focus on one-directional communication frames the students' understanding of the courses and their performance in it. They learn that: (1) meeting a real patient is a rare opportunity, (2) engaging patients' thoughts and feelings in the conversation is challenging, and (3) the biomedical aspect should be prioritized in the conversation. Insights: These findings suggested that the medical curriculum we studied gave limited room for patient-centered medicine, even in communication training. The power of macro-level documents framed and focused micro-level learning activities and could help explain observed disharmonies in patient-medical student encounters. We see how patient-centered medicine - in both texts and practice - is represented and enacted as a peripheral activity and patients are given a marginal position in encounters with students. The findings suggested that there are challenges for progress and change toward a more patient-centered communication training and curriculum. However, empirical findings also offered points of departure for course leaders and curriculum planners wishing to take steps toward a stronger and more reflective patient-centered approach in medical education, supported through the document structure and the translation of the curriculum through relevant learning activities.

Embedding Identity and How Clinical Teachers Reconcile Their Multiple Professional Identities to Meet Overlapping Demands at Work.

PHENOMENON: Clinical teachers perform overlapping tasks in education and patient care. They are therefore expected to juggle many professional identities such as educator and clinician. Yet little is known about how clinical teachers negotiate their professional identities. The present research examined the lived experiences of clinical teachers as they manage and make sense of their professional identities in the context of a faculty development program. APPROACH: This study adopted interpretative phenomenological analysis, which is an idiographic and inductive methodological approach that enables an in-depth examination of how people conceptualize their personal and social worlds. In-depth semi-structured individual interviews were conducted with six purposively sampled Brazilian clinical teachers who were attending a faculty development program. Each participant's lived experience was analyzed independently. Then, these individual analyses were compared against each other to identify convergence and divergence. FINDINGS: Participants recognized one identity, which was labeled as embedding identity, containing other identities and roles. Participants integrated their professional identities in agreement with their personal identities, values, and beliefs, striving thus for identity consonance. Participants understood their craft as a relational process by which they wove themselves into their context and entangled their experience with that of others. They, however, diverged when recognizing who their peers were; whereas some named a single professional group (i.e., family physicians), others had a more comprehensive view and considered as peers healthcare professionals, students, and even patients. Finally, participants identified time constraints and lower prestige of family medicine as a medical discipline vis-à-vis other specialties as challenges posed by their contexts. INSIGHTS: Clinical teachers have multifaceted identities, to which they give a sense, manage, and integrate into their daily practice. Participants recognized an embedding identity and looked for common points between the identities it contained, which allowed them to meaningfully reconcile the different demands from their overlapping professional identities. Thus, this research introduces the notion of embedding identity as a strategy to make sense of many professional identities. Variability in the embedding identities depicted in this investigation suggests the fluid and contextualized character of professional identity development. How participants saw themselves also influenced how they behaved and interacted with others accordingly. Understanding clinical teacher identity development enriches current perspectives of what it is like to be one of these medical professionals. Faculty development programs ought to consider these perspectives to better support clinical teachers in meeting the overlapping demands in education and patient care.

'You should see a doctor', said the robot: Reflections on a digital diagnostic device in a pandemic age.

AIMS: In three days at the beginning of the COVID-19 pandemic, the Copenhagen Emergency Medical Services developed a digital diagnostic device. The purpose was to assess and triage potential COVID-19 symptoms and to reduce the number of calls to public health-care helplines. The device was used almost 150,000 times in a few weeks and was described by politicians and administrators as a solution and success. However, high usage cannot serve as the sole criterion of success. What might be adequate criteria? And should digital triage for citizens by default be considered low risk? METHODS: This paper reflects on the uncertain aspects of the performance, risks and issues of accountability pertaining to the digital diagnostic device in order to draw lessons for future improvements. The analysis is based on the principles of evidence-based medicine (EBM), the EU and US regulations of medical devices and the taxonomy of uncertainty in health care by Han et al. RESULTS: Lessons for future digital devices are (a) the need for clear criteria of success, (b) the importance of awareness of other severe diseases when triaging, (c) the priority of designing the device to collect data for evaluation and (d) clear allocation of responsibilities. CONCLUSIONS: A device meant to substitute triage for citizens according to its own criteria of success should not by default be considered as low risk. In a pandemic age dependent on digitalisation, it is therefore important not to abandon the ethos of EBM, but instead to prepare the ground for new ways of building evidence of effect.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing.

BACKGROUND: How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. METHOD: The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. RESULTS: Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. CONCLUSION: Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Beyond the cultural myth of medical meritocracy.

BACKGROUND: We examine the cultural myth of the medical meritocracy, whereby the "best and the brightest" are admitted and promoted within the profession. We explore how this narrative guides medical practice in ways that may no longer be adequate in the contexts of practice today. METHODS: Narrative analysis of medical students' and physicians' stories. RESULTS: Hierarchies of privilege within medicine are linked to meritocracy and the trope of the "hero's story" in literature. Gender and other forms of difference are generally excluded from narratives of excellence, which suggests operative mechanisms that may be contributory to observed differences in attainment. We discuss how the notion of diversity is formulated in medicine as a "problem" to be accommodated within merit, and posit that medical practice today requires a reformulation of the notion of merit in medicine, valorising a diversity of life experience and skills, rather than "retrofitting" diversity concerns as problems to be accommodated within current constructs of merit. CONCLUSIONS: Three main action-oriented outcomes for a better formulation of merit relevant to medical practice today are suggested: (a) development of assessors' critical consciousness regarding the structural issues in merit assignment; (b) alignment of merit criteria with relevant societal outcomes, and (c) developing inclusive leadership to accommodate the greater diversity of excellence needed in today's context of medical practice. A reformulation of the stories through which medical practitioners and educators communicate and validate aspects of medical practice will be required in order for the profession to continue to have relevance to the diverse societies it serves.

Trail Blazing or Jam Session? Towards a New Concept of Clinical Decision-making.

Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to 'trail blazing'; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image. This paper presents the exploration of this discrepancy in the heart of medical practice and how an alternative image emerged; that of a 'jam session'. The exploration is represented as a case-based hypothesis-testing: first, a theoretically and empirically informed hypothesis (H0) of how doctors perform CDM is developed. In H0, CDM is a stepwise process of reasoning about clinical data, often influenced by outside contextual factors. Then, H0 is tested against a case from ethnographic fieldwork with doctors going through internship. Although the case is chosen for characteristics that make it 'most likely' to verify the hypothesis, verification proves difficult. The case challenges preconceptions in CDM literature about chronology, context, objectivity, cognition, agency, and practice. The young doctor is found not to make decisions, but rather to participate in CDM; an activity akin to the dynamics found in a jam session. Their participation circles in and through four concurrent interrelated constructions that suggest a new conceptualization of CDM; a starting point for a deeper understanding of actual practice in a changing clinical environment.

Speed, accuracy, and efficiency: The promises and practices of digitization in pathology.

Digitization is often presented in policy discourse as a panacea to a multitude of contemporary problems, not least in healthcare. How can policy promises relating to digitization be assessed and potentially countered in particular local contexts? Based on a study in Denmark, we suggest scrutinizing the politics of digitization by comparing policy promises about the future with practitioners' experience in the present. While Denmark is one of the most digitalized countries in the world, digitization of pathology has only recently been given full policy attention. As pathology departments are faced with an increased demand for pathology analysis and a shortage of pathologists, Danish policymakers have put forward digitization as a way to address these challenges. Who is it that wants to digitize pathology, why, and how does digitization unfold in routine work practices? Using online search and document analysis, we identify actors and analyze the policy promises describing expectations associated with digitization. We then use interviews and observations to juxtapose these expectations with observations of everyday pathology practices as experienced by pathologists. We show that policymakers expect digitization to improve speed, patient safety, and diagnostic accuracy, as well as efficiency. In everyday practice, however, digitization does not deliver on these expectations. Fulfillment of policy expectations instead hinges on the types of artificial intelligence (AI) applications that are still to be developed and implemented. Some pathologists remark that AI might work in the easy cases, but this would leave them with only the difficult cases, which they consider too burdensome. Our particular mode of juxtaposing policy and practice throws new light on the political work done by policy promises and helps to explain why the discipline of pathology does not seem to easily lend itself to the digital embrace.

'If you had taken the lead ' - a qualitative study of patients with chronic conditions and their perspective in clinical encounters with medical students.

OBJECTIVES: To explore what patients with chronic conditions emphasize as important in the patient-medical student conversation, and how the patients' experiences relate to trust. METHODS: Twenty-one video-recorded sessions of patients' feedback in simulation-based communication courses for medical students were observed, transcribed, analyzed inductively and organized into three themes. RESULTS: In the patients' feedback, three aspects were emphasized as important relating to trust: a) when the medical student relates medical information to the patient's lifeworld, b) when the student leads the patient throughout the conversation, and c) when the patient gets emotional support from the student. The patients felt that being met this way by the students grows trust and allows them to lean into the uncertainties they experience while still feeling safe. DISCUSSION: The patients emphasize three aspects of importance in conversations with the medical students that grow trust. We argue that these aspects cannot be found in the traditional authority-led practice but can be found in leadership, which imply empathy and willingness to learn from patients. We suggest that students should learn that to effectively communicate with patients infers such leadership. By doing so, medical students can walk alongside their patients to build a relationship and nurture trust.

Surrendering to the Process: Innovation in Developing CPD for General Practice.

In CME/CPD, a significant part of research is about effectiveness. Attention to the development process can be vital to understand how it impacts progress and results. This study aims to explore an innovative process of applying a combined approach using design-based research, collaborative innovation, and program theory to develop CPD about type 2 diabetes for GPs and clinic nurses with a group of interprofessional stakeholders. In particular, the development process of the combined approach and how it impacts the progress and the activities. We applied two qualitative methods. First, we analysed 159 documents from the development process, and second, eight semi-structured key informant interviews. Data were deductively analysed using 15 predefined elements derived from the combined approach combined with open coding analyses. The analysis showed how the combined approach structured the process. And the interviews broadened our understanding of the relationship between the process and the activities. Four additional themes were constructed from the open coding, including surrender to the process. Surrendering was a central part of the interviewees' participation in the process. The combined approach facilitated this unfamiliar experience of surrender. By supporting participants to surrender, the combined approach enabled an expansion of interprofessional collaboration and the development of innovative activities and learning methods in CPD on type 2 diabetes.