A therapeutic intervention for an ailing medical education: The values prism model as proof of concept.

PURPOSE: To articulate proof of concept in relation to a complex pedagogical values intervention for a range of medical education's historically accumulated symptoms. METHODS: Using a discursive approach, symptoms that hinder development of medical education are set out. Such symptoms rest with the instrumentality of current pedagogical approaches, supressing potential. A 'cure' is articulated - that the dominant values complex of instrumentalism is raised in quality through embracing ethical, aesthetic, political, and transcendental (meaning) values. Key to this is the use of language in clinical encounters, where the productive metaphor count is repressed in instrumental-technical approaches but multiplied in embracing other values and qualities. This 'Values Prism' model shows instrumentalism passing through an expansive educational prism to create expansion in types and qualities. RESULTS AND CONCLUSIONS: Proof of concept is achieved. The Values Prism model can be adapted for any undergraduate medicine curriculum as a process model - a set of values that permeate the curriculum beyond the dominant instrumental. The enhanced and expanded curriculum acts in a translational capacity.

As 'synapses' become 'protoplasmic kisses': Symmetry across clinical reasoning and poetry.

CONTEXT: We argue that biomedicine at root is not primarily instrumental, but shares aesthetic, ethical and political values with poetry. Yet an instrumentalist bias in medical pedagogy can lead to frustration of biomedicine's potential. Such unfulfilled potential is exposed when making a comparison with poetry, a knowledge system that expressly engages a range of value systems. How then to recover biomedical language's riches for medical education's gain? METHODS: We combine scientific and artistic approaches by positing a common frame to which both medicine and poetry can aspire: the 'high-water mark' of language. Poetry's language is complex, intensive and connotative-concerned with mood, ambiguity, metaphor and embodiment. Biomedicine potentially engages with such linguistic complexities, particularly in metaphor production, yet persistently falls away from this high-water mark of language, reducing connotative language to denotation or literal meanings. We describe such instances of frustrated potential as 'trying to accelerate with the brake on'. This paradoxical state has become habitual in medical education. The resultant lack of productive metaphor insulates pedagogy from mood, separating it from the vernacular as a specialist tongue that ensures identification with the medical community of practice. Such language can alienate both patients and poets for the same reason: it is less human than technical. CONCLUSIONS: Using the example of clinical reasoning and attendant diagnostic work, we show that reductions from the connotative to the denotative not only mask but also contradict the complexity of implicit, embedded and distributed cognitive structures, creating a tension that medical education consistently fails to either resolve or draw upon as a resource. Further, poetry too has a complex set of implicit rules and formative structures that shape composition. These structures show symmetry, correspondence or even isomorphism with medical cognition, where both can aspire to activity that is aesthetically rich, intense and cognitively elegant.

Empathy across cultures - one size does not fit all: from the ego-logical to the eco-logical of relational empathy.

Empathy is extolled in Western healthcare and medical education as an exemplary quality to cultivate in trainees and providers. Yet it remains an elusive and inadequately understood attribute. It posits a "one size fits all" unidimensional attribute applicable across contexts with scant attention given to its multifaceted dimensions in intercultural contexts. In this article, we uncloak the shortcomings of this conventional empathy in intercultural settings, and instead propound an expanded "relational empathy".

Where medical education meets artificial intelligence: 'Does technology care?'

'COLD' TECHNOLOGIES AND 'WARM' HANDS-ON MEDICINE NEED TO WALK HAND-IN-HAND: Technologies, such as deep learning artificial intelligence (AI), promise benign solutions to thorny, complex problems; but this view is misguided. Though AI has revolutionised aspects of technical medicine, it has brought in its wake practical, conceptual, pedagogical and ethical conundrums. For example, widespread adoption of technologies threatens to shift emphasis from 'hands-on' embodied clinical work to disembodied 'technology enhanced' fuzzy scenarios muddying ethical responsibilities. Where AI can offer a powerful sharpening of diagnostic accuracy and treatment options, 'cold' technologies and 'warm' hands-on medicine need to walk hand-in-hand. This presents a pedagogical challenge grounded in historical precedent: in the wake of Vesalian anatomy introducing the dominant metaphor of 'body as machine,' a medicine of qualities was devalued through the rise of instrumental scientific medicine. The AI age in medicine promises to redouble the machine metaphor, reducing complex patient experiences to linear problem-solving interventions promising 'solutionism.' As an instrumental intervention, AI can objectify patients, frustrating the benefits of dialogue, as patients' complex and often unpredictable fleshly experiences of illness are recalculated in solution-focused computational terms. SUSPICIONS ABOUT SOLUTIONS: The rate of change in numbers and sophistication of new technologies is daunting; they include surgical robotics, implants, computer programming and genetic interventions such as clustered regularly interspaced short palindromic repeats (CRISPR). Contributing to the focus of this issue on 'solutionism,' we explore how AI is often promoted as an all-encompassing answer to complex problems, including the pedagogical, where learning 'hands-on' bedside medicine has proven benefits beyond the technical. Where AI and embodied medicine have differing epistemological, ontological and axiological roots, we must not imagine that they will readily walk hand-in-hand down the aisle towards a happy marriage. Their union will be fractious, requiring lifelong guidance provided by a perceptive medical education suspicious of 'smart' solutions to complex problems.

Re-visioning clinical reasoning, or stepping out from the skull.

THE PROBLEM: Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts. A SOLUTION: Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, 'extended' cognition is configured as an outside-in process of 'sensemaking' or 'adaptive expertise'. THE FUTURE: Current 'predictive processing' cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an 'ecological perception' or 'externalistic' model provides a counter to the current dominant paradigm of 'ego-logical' cognitive reasoning - the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.

Embracing ambiguity: Curriculum design and activity theory.

A curriculum innovation for a new UK medical school - Peninsula, launched in 2002 - was grounded in a period of radical pedagogical innovation in medical education in the UK during the 1990s. Part of this thinking was to include the medical humanities as a medium for re-thinking medical practice, especially how medical students might better learn to communicate with patients and colleagues, and how they might become agents of change in progressing medicine through innovations. In designing the curriculum, Cultural-historical Activity Theory (CHAT) was used as a model to 'think', or reconceptualise, the purposes of a curriculum. The first question asked was: 'what do patients want?' Emphasis was placed on resisting a 'will-to-stability' in adopting safe curriculum process, in favour of adopting a 'possibility knowledge' framework that celebrated dialogue. This operated through three 'spearheads', or radical aims: democratic habits, towards the feminine, and tender-mindedness.

Embracing the collective through medical education.

The journal Advances in Health Sciences Education: Theory and Practice has, under Geoff Norman's leadership, promoted a collaborative approach to investigating educationally-savvy and innovative health care practices, where academic medical educators can work closely with healthcare practitioners to improve patient care and safety. But in medical practice in particular this networked approach is often compromised by a lingering, historically conditioned pattern of heroic individualism (under the banner 'self help'). In an era promising patient-centredness and inter-professional practices, we must ask: 'when will medicine, and its informing agent medical education, embrace democratic habits and collectivism?' The symptom of lingering heroic individualism is particularly prominent in North American medical education. This is echoed in widespread resistance to a government-controlled public health, where the USA remains the only advanced economy that fails to provide universal health care. I track a resistance to collectivist medical-educational reform historically from a mid-nineteenth century nexus of influential thinkers who came, some unwittingly, to shape North American medical education within a Protestant-Capitalist individualist tradition. This tradition still lingers, where some doctors recall a fictional 'golden age' of medical practice and education, actually long since eclipsed by fluid inter-professional health care team practices. I cast this tension between conservative traditions of individualism and progressive collectivism as a political issue.

What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings.

Top-down policy directives, such as targets and their associated protocols, may be driven politically rather than clinically and can be described as macro-political texts. While targets supposedly provide incentives for healthcare services, they may unintentionally shape practices of accommodation rather than implementation, deflecting practitioners from providing optimal care. Live work activities were observed for two six months periods in a UK NHS Emergency Department and a Mental Health Ward using video and field notes ethnography, with post hoc unstructured interviews for clarification and verification. Sixty-four practitioners were consented. Data were treated as narratives, analysed thematically and theorised using cultural-historical activity theory. The ideal text of patient-centred team working shaped by top-down, politically inspired targets was disrupted, where targets produced unintended consequences. Bottom-up strategies of making meaning of targets in a local context generated sub-texts of resistance, rationalization, and even duplicity that had paradoxical positive effects in generating collaboration and democratic habits. Throughput pressures generated both cross-team conflicts and intra-team identification. What practitioners actually do to make sense of top-down directives is not the same as the ideal expectation framed by targets. Team members pulled together not because of targets but in spite of them, and as a form of resistance to governance. Targets produce unnecessary stress as team members focus on throughput rather than quality of care. Those governing healthcare must look at the unintended consequences of targets.

Whistleblowing in medicine and in Homer's Iliad.

'Thinking with Homer', or drawing creatively on themes and scenes from Homer's Iliad and Odyssey, can help us to better understand medical culture and practice. One current, pressing, issue is the role of the whistleblower, who recognises and exposes perceived poor practice or ethical transgressions that compromise patient care and safety. Once, whistleblowers were ostracised where medical culture closed ranks. However, in a new era of public accountability, medicine looks to formally embrace whistleblowing to the point that not reporting transgressions can now constitute a transgression of professionalism. Where medical students identify with the history and traditions of medical culture, they inevitably find themselves in situations of conflicting loyalties if they encounter senior clinicians behaving unprofessionally. What are the implications of facing these dilemmas for students in terms of role modelling and shaping of character as a doctor, and how might a study of Homer help with such dilemmas? We suggest that a close reading of an opening scene in Homer's the Iliad can help us to better appreciate such ethical dilemmas. We link this with the early Greek tradition of parrhesia or 'truth telling', where frankly speaking out against perceived injustice is encouraged as resistance to power and inappropriate use of authority. We encourage medical educators to openly discuss perceived ethical dilemmas with medical students, and medicine as a culture to examine its conscience in a transition from an authoritarian to an 'open' society, where whistleblowing becomes as acceptable and necessary as good hygiene on the wards.

Gender matters in medical education.

CONTEXT: Women are in the majority in terms of entry to medical schools worldwide and will soon represent the majority of working doctors. This has been termed the 'feminising' of medicine. In medical education, such gender issues tend to be restricted to discussions of demographic changes and structural inequalities based on a biological reading of gender. However, in contemporary social sciences, gender theory has moved beyond both biology and demography to include cultural issues of gendered ways of thinking. Can contemporary feminist thought drawn from the social sciences help medical educators to widen their appreciation and understanding of the feminising of medicine? DISCUSSION: Post-structuralist feminist critique, drawn from the social sciences, focuses on cultural practices, such as language use, that support a dominant patriarchy. Such a critique is not exclusive to women, but may be described as supporting a tender-minded approach to practice that is shared by both women and men. The demographic feminising of medicine may have limited effect in terms of changing both medical culture and medical education practices without causing radical change to entrenched cultural habits that are best described as patriarchal. Medical education currently suffers from male biases, such as those imposed by 'andragogy', or adult learning theory, and these can be positively challenged through post-structuralist feminist critique. CONCLUSIONS: Women doctors entering the medical workforce can resist and reformulate the current dominant patriarchy rather than reproducing it, supported by male feminists. Such a feminising of medicine can extend to medical education, but will require an appropriate theoretical framework to make sense of the new territory. The feminising of medical education informed by post-structuralist frameworks may provide a platform for the democratisation of medical culture and practices, further informing authentic patient-centred practices of care.

Can the science of communication inform the art of the medical humanities?

CONTEXT: There is increasing interest in establishing the medical humanities as core integrated provision in undergraduate medicine curricula, but sceptics point to the lack of evidence for their impact upon patient care. Further, the medical humanities culture has often failed to provide a convincing theoretical rationale for the inclusion of the arts and humanities in medical education. DISCUSSION: Poor communication with colleagues and patients is the main factor in creating the conditions for medical error; this is grounded in a historically determined refusal of democracy within medical work. The medical humanities may play a critical role in educating for democracy in medical culture generally, and in improving communication in medical students specifically, as both demand high levels of empathy. Studies in the science of communication can provide a valuable evidence base justifying the inclusion of the medical humanities in the core curriculum. A case is made for the potential of the medical humanities--as a form of 'adult play'--to educate for collaboration and tolerance of ambiguity or uncertainty, providing a key element of the longer-term democratising force necessary to change medical culture and promote safer practice. CONCLUSION: The arts and humanities can provide important contextual media through which the lessons learned from the science of communication in medicine can be translated and promoted as forms of medical education.

'Achieving ensemble': communication in orthopaedic surgical teams and the development of situation awareness--an observational study using live videotaped examples.

Focused dialogue, as good communication between practitioners, offers a condition of possibility for development of high levels of situation awareness in surgical teams. This has been termed "achieving ensemble". Situation awareness grasps what is happening in time and space with regard to one's own unfolding work in relation to that of colleagues, and is necessary to maintain patient safety throughout a surgical list. We refined a typology, initially developed for use in studying the dynamics of teams in aviation safety, of 10 kinds of communication within two broad areas: 'Reports', or authoritative acts of communication setting up a monological or authoritative climate; and 'Requests', or facilitative acts of communication setting up a dialogical or participatory climate. We systematically mapped how orthopaedic surgical teams use verbal communication through analysis of videotaped operations using the typology. We asked: 'do orthopaedic surgical teams set up the conditions of possibility for the emergence of situation awareness through effective communication?' We found that orthopaedic surgical teams tend to produce monological rather than dialogical climates. Dialogue increases with more complex cases, but in routine work, communication levels are depressed and one-way, influenced by surgeons working within a traditionally hierarchical and authoritative culture. We suggest that such a monological climate inhibits development of situation awareness and then compromises patient safety. The same teams, however, generate potentially rich educational climates through exchange of profession-specific knowledge and skills, and we suggest that where technical skill exchange is good, non-technical or interpersonal communication skill levels can follow.

Working in "teams" in an era of "liquid" healthcare: what is the use of theory?

"Team" is used throughout the healthcare literature as if it had a transparent, single meaning, and in policy documents it has become a mantra. Yet, "team" is a contested and imprecise term, inviting theoretical sophistication. New forms of team working in healthcare contexts can be understood as a complex set of practices and a discourse--both performed, and written and talked about as a supplementary practice. In the context of fluid and unpredictable social conditions, teams are now theorized in terms of contradictory process as well as stable membership. Cultural-historical activity theory in particular provides a rich approach to understanding such process, in an era where the desire for stable networks--a will-to-stability--may be secondary to the need for a will-to-adaptability. A new vocabulary has emerged in theoretical accounts to describe activities of an emergent work order, in terms of a shift from stable "networking" to unstable "knotworking." However, this conceptual language can be overwrought and may alienate practitioners. Theory can be developed with practitioners themselves to avoid widening the gap between experience and the understanding and explanation of experience. Teams are not problems to be solved but activities to be expanded.

The dislocation of medical dominance: making space for interprofessional care.

The historical transition of modern medicine from an autonomous profession to a team-based interprofessional practice can be described in terms of space rather than time, with "place" as the unit of analysis. Imagining modern medicine spatially was instigated by Foucault, who described medical dominance as a territorializing of both individual body spaces and public spaces--the former through the diagnostic medical gaze, the latter in a gaze of health surveillance. However, much has happened since Foucault's (1963) analysis. The diagnostic gaze has been dispersed to develop a collaborative gaze including patients and healthcare professionals; political interests have appropriated the public health gaze; and the medical profession is subject to democratic processes of accountability. Medicine has lost its territorial imperative as new "liquid" and "nomadic" work practices emerge, making space for interprofessional care. Such dislocation of medical dominance and its multiple relocations are poorly theorised. Deleuze and Guattari distinguish between "striated" and "smooth" spaces. Striated space is associated with hierarchies and boundaries, where smooth space includes boundary crossing and democratic collaboration. Smooth or liminal spaces in hospitals, such as corridors, can paradoxically act as catalysts for collaboration or assembly democracy, affording opportunities for improvised interprofessional encounters. Such encounters can act as an antidote to planned protocols or imperatives for interprofessional collaboration.

Lost in translation. Homer in English; the patient's story in medicine.

In a series of previous articles, we have considered how we might reconceptualise central themes in medicine and medical education through 'thinking with Homer'. This has involved using textual approaches, scenes and characters from the Iliad and Odyssey for rethinking what is a 'communication skill', and what do we mean by 'empathy' in medical practice; in what sense is medical practice formulaic, like a Homeric 'song'; and what is lyrical about medical practice. Our approach is not to historicise medicine and medical education, but to use thinking with Homer as a medium and metaphor for questioning the habitual and the taken-for-granted in contemporary practice. In this article, we tackle the complex theme of 'translation'. We use the lens of translation studies to examine the process of turning the patient's story into medical language. We address the questions: what makes a 'good' translation? What are the consequences of mistranslation and poor translation? And, while things are inevitably lost in translation, does this matter?

Maximising medicine through aphorisms.

CONTEXT: Aphorisms are succinct sayings that offer advice. They have permanently coloured medical culture and inhabit it in the same way as uncertainty; they are acknowledged, but rarely explored. Little has been written analytically or critically about the meanings and purposes of aphorisms in contemporary medical education, especially as a processional activity that maintains tradition, but both adds to and reframes it. DISCUSSION: We note multiple purposes for medical aphorisms, including roles as heuristics (rules of thumb) for practice, and in the identity construction of the clinician within a community beset by professional uncertainty and accountability. We suggest that aphorisms should be cared for not simply as historical curiosities, but as renewable ways of creating an 'art of memory' in medical education, stimulating recognition and recall as aesthetic rhetorical devices. In this spirit, we encourage the development of aphorisms appropriate for 21st century medicine in a process that should include the involvement of patients in building a proxy public literacy to inform collaboration in clinical encounters. CONCLUSIONS: We propose a novel framework for aphorisms, emphasising strategies to enhance or maximise clinical judgement and professional behaviour, affirm identities, and educate the public via the media.

Writing out prescriptions: hyperrealism and the chemical regulation of mood.

Using contemporary literary sources, we explore the powerful ideological framework that normalises prescription dependency as part of everyday life, focusing upon the treatment of mood disorders. Through a literary critical methodology, we read novels by American hyperrealists such as Bret Easton Ellis, David Foster Wallace and Rick Moody as symptomatic of prescription culture. Though we argue that these writers brilliantly understand the dangers of mood medication, they do not escape its logic, rather, 'writing it out' as they write against it. Indeed, we propose that their novels bear ironic similarities to medical texts such as the British National Formulary, usually seen as a neutral handbook for physicians' guidance in prescribing. We explicate their method as that of deconstruction, which, in contrast to more obvious critiques of chemical treatment, such as therapy, neither analyses nor cures. Though this method underplays the possibility of pragmatic and political resistance exemplified by alternative formularies such as the long-established feminist health manual Our Bodies, Ourselves, we argue that its very ambiguity uniquely exposes the complex determinisms associated with prescribed medication. We thus propose the value of drawing on deconstructive literature to better understand 'health' interventions such as prescription drugs for the regulation of mood.

The curriculum is dead! Long live the curriculum! Designing an undergraduate medicine and surgery curriculum for the future.

Where changing social circumstances demand reform of medicine, this in turn provokes new thinking in medical education. Curriculum changes, however, are often ill conceived, consisting of syllabus (content) modification, rather than careful consideration of fundamental principles and theory shaping a curriculum process initiative. The undergraduate medicine and surgery curriculum of the future must address some basic fault lines in current provision, such as medical culture's failure to democratise work practices ensuring patient safety. While acquiring a reputation as innovative and progressive, and after a decade of success with current provision, Peninsula Medical School (UK) has recognised the need to develop its curriculum for the future. Such a curriculum will be guided by best evidence from medical education to inform pedagogical practices and by sophisticated curriculum theory. Drawing on social learning pedagogies and curriculum reconceptualisation models for guidance, and incorporating evaluation of its current provision and published evaluations of other curricula (particularly Longitudinal Integrated models), fundamental principles were conceived to guide curriculum reform.

The proof is in the pudding: putting Actor-Network-Theory to work in medical education.

What constitutes valid evidence from medical education research is typically grounded in the scientific paradigm of proof through experiment. Here, explanation through single meaning is privileged over exploration of multiple presentations of phenomena--short, interpretation eclipses appreciation. This approach is challenged as reductive by naturalistic qualitative methods such as rich ethnographic field reports, presented as narratives. Contemporary ethnographic approaches have entered medical education by a back door--disguised as a stable of 'social learning theories'. Communities of Practice theory, Activity Theory and Actor-Network-Theory (ANT) all serve as research practices forming identifiable contemporary ethnographies. 'Evidence' is conceived as exploratory rather than explanatory, through baroque descriptions of innovations in learning organizations, including medicine. ANT is then both a theory of innovation in organizations and an ethnographic method, where practice and theory coincide. ANT is interested primarily not in epistemologies, but in how a phenomenon such as an 'illness' is conceived across differing practices as multiple ontologies (experienced meanings), each meaning generated and suspended within a particular network of effects. How such networks are initiated and developed has significance for rethinking the nature of 'evidence', restoring faith in the value of a good story.