Exploring yarigai: The meaning of working as a physician in teaching medical professionalism.

INTRODUCTION: The shift in medical professionalism now considers the well-being of physicians, given the prevalence of burnout and the importance of work-life balance. To reconsider the question 'Why do doctors work for the patient?' and explore the meaning of working as a physician, this study adopts the concept of 'yarigai,' which represents fulfillment and motivation in meaningful work. The authors' research questions are: How do doctors recount experiences of yarigai in caring for patients? What kind of values are embodied in their stories about yarigai? METHOD: They adopted narrative inquiry as the methodology for this study. They interviewed 15 doctors who were recognized by their colleagues for their commitment to patient-centered care or had demonstrated yarigai in caring for patients. The semi-structured interviews were conducted face-to-face with each participant by the Japanese researchers, yielding 51 cases of patient-doctor interactions. After grouping the interview data, they translated the cases into English and identified four representative cases to present based on the set criteria. RESULTS: From the 51 case studies, they constructed four representative narratives about the yarigai as a physician. Each of them spoke of (1) finding positive meaning in difficult situations, (2) receiving gifts embodying ikigai, (3) witnessing strength in a seemingly powerless human being, and (4) cultivating relationships that transcend temporal boundaries, as being rewarding in working as a physician. The main results of the study, which are the narratives, are described in the main body of the paper. CONCLUSION: The stories on yarigai gave intrinsic meanings to their occupational lives, which can be informative for students, residents, and young physicians when contemplating the meaning of their work as doctors. Rather than demanding selfless dedication from physicians towards patients, they believe it more important to foster yarigai, derived from the contribution to the well-being of others through patient care.

Striking fear into students' hearts: Unforeseen consequences of prescribing education.

PURPOSE: Undergraduate medical education (UGME) has to prepare students to do safety-critical work (notably, to prescribe) immediately after qualifying. Despite hospitals depending on them, medical graduates consistently report feeling unprepared to prescribe and they sometimes harm patients. Research clarifying how to prepare students better could improve healthcare safety. Our aim was to explore how students experienced preparing for one of their commonest prescribing tasks: intravenous fluid therapy (IVFT). METHODS: Complexity assumptions guided the research, which used a qualitative methodology oriented towards hermeneutic phenomenology. The study design was an uncontrolled and unplanned complex intervention: judicial review of the iatrogenic death of five children due to hyponatraemia in our region had resulted in the recommendation that students' education in 'the implementation of important clinical guidelines' relevant to fluid and electrolyte balance should be intensified. An opportunity sample of 40 final-year medical students drew and gave audio-recorded commentaries on rich pictures. We completed two template analyses: one of participants' transcribed commentaries on the pictures and one using a novel heuristic to analyse the pictures themselves. We then reconciled the two analyses into a single template. RESULTS: There were four themes: affects, teaching and learning, contradictions, and the curriculum as a journey. To explore interconnections between themes, we chose the picture best exemplifying each of the four themes and interpreted the curriculum journey depicted in each of them. These interpretations were grounded in each participant's picture, verbal account of the picture, and the aggregate findings of the template analysis. Participants' experiences were influenced by the situated complexity of IVFT. Layered on top of that, contradictions, overlaps, and gaps within the curriculum introduced extraneous complexity. Confusion and apprehension resulted. CONCLUSIONS: After spending five years preparing to prescribe IVFT, participants felt unprepared to do so. We conclude that intensive teaching had not achieved its avowed goal of improving students' preparedness for safe practice. Merton's seminal work on the 'unanticipated consequences of purposive social action' suggests that intensive teaching may even have contributed to their unpreparedness.

Constraints and affordances for UK doctors-in-training to exercise agency: A dialogical analysis.

INTRODUCTION: The goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors-in-training. METHODS: This was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors-in-training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi-structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency. RESULTS: When talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors-in-training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care. CONCLUSIONS: Our findings identified some organisational changes needed for doctors-in-training to practise effectively and learn from work. The findings also highlight a need to improve workplace-based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors-in-training, which will ultimately benefit patients.

Reluctant heroes: New doctors negotiating their identities dialogically on social media.

BACKGROUND: Ensuring that students transition smoothly into the identity of a doctor is a perpetual challenge for medical curricula. Developing professional identity, according to cultural-historical activity theory, requires negotiation of dialectic tensions between individual agency and the structuring influence of institutions. We posed the research question: How do medical interns, other clinicians and institutions dialogically construct their interacting identities? METHODS: Our qualitative methodology was rooted in dialogism, Bakhtin's cultural-historical theory that accounts for how language mediates learning and identity. Reasoning that the COVID pandemic would accentuate and expose pre-existing tensions, we monitored feeds into the Twitter microblogging platform during medical students' accelerated entry to practice; identified relevant posts from graduating students, other clinicians and institutional representatives; and kept an audit trail of chains of dialogue. Sullivan's dialogic methodology and Gee's heuristics guided a reflexive, linguistic analysis. RESULTS: There was a gradient of power and affect. Institutional representatives used metaphors of heroism to celebrate 'their graduates', implicitly according a heroic identity to themselves as well. Interns, meanwhile, identified themselves as incapable, vulnerable and fearful because the institutions from which they had graduated had not taught them to practise. Senior doctors' posts were ambivalent: Some identified with institutions, maintaining hierarchical distance between themselves and interns; others, along with residents, acknowledged interns' distress, expressing empathy, support and encouragement, which constructed an identity of collegial solidarity. CONCLUSIONS: The dialogue exposed hierarchical distance between institutions and the graduates they educated, which constructed mutually contradictory identities. Powerful institutions strengthened their identities by projecting positive affects onto interns who, by contrast, had fragile identities and sometimes strongly negative affects. We speculate that this polarisation may be contributing to the poor morale of doctors in training and propose that, to maintain the vitality of medical education, institutions should seek to reconcile their projected identities with the lived identities of graduates.

Fifteen-minute consultation: Guide to communicating with children and young people.

This article suggests communicative steps and strategies to help healthcare professionals achieve the ideals of child-centred care, which place children and young people at the centre of policy and practice. For those with 15 s, not 15 min, our suggestions can be summarised like this: help children be active agents in their own care by asking, listening well, being curious and explaining things clearly in an accessible but not condescending way.

Pre-prescribing: Creating a zone of proximal development where medical students can safely fail.

PURPOSE: Prescribing is a common task, often performed by junior clinicians, with potential for significant harm. Despite this, it is common for medical students to qualify having only prescribed in simulated scenarios or assessments. We implemented an alternative: students were given pens with purple ink, which permitted them to write prescriptions for real patients. We set out to understand how this intervention, pre-prescribing, created a zone of proximal development (ZPD) for learners. METHODS: An anonymous, mixed methods, evaluation questionnaire was distributed to all final-year medical students at one university in the United Kingdom. Analysis was guided by Experience Based Learning theory. RESULTS: Two hundred and eighteen students made 386 free-text comments. Most participants reported that pre- helped them become capable doctors (Strongly Agree n = 96, 45%; Agree: n = 110, 50%). Pre-prescribing created a ZPD in which participants could use the tools of practice in authentic contexts under conditions that made it safe to fail. CONCLUSIONS: This research shows how a theoretically informed intervention can create conditions to enhance learning. It encourages educators to identify aspects of routine practice that could be delegated, or co-performed, by learners. With appropriate support, educators can create 'safe-fails' which allow learners to participate safely in authentic, risky, and indeterminate situations they will be expected to navigate as newly qualified clinicians.

The social construction of teacher and learner identities in medicine and surgery.

INTRODUCTION: There are growing concerns about the quality and consistency of postgraduate clinical education. In response, faculty development for clinical teachers has improved formal aspects such as the assessment of performance, but informal work-based teaching and learning have proved intractable. This problem has exposed a lack of research into how clinical teaching and learning are shaped by their cultural contexts. This paper explores the relationship between teacher-learner identity, educational practice and the workplace educational cultures of two major specialties: internal medicine and surgery. METHODS: This was a secondary analysis of a large dataset, comprising field notes, participant interviews, images and video-recordings gathered in an ethnographic study. The lead author embedded himself in four clinical teams (two surgical and two medical) in two different hospitals. The authors undertook a critical reanalysis of the observational dataset, using Dialogism and Figured Worlds theory to identify how teachers and postgraduate learners figured and authored their professional identities in the specialty-specific cultural worlds of surgery and internal medicine. RESULTS: Surgery and internal medicine privileged different ways of being, knowing and talking in formal and informal settings, where trainees authored themselves as capable practitioners. The discourse of surgical education constructed proximal coaching relationships in which trainees placed themselves at reputational risk in a closely observed, embodied practice. Internal medicine constructed more distal educational relationships, in which trainees negotiated abstract representations of patients' presentations, which aligned to a greater or lesser degree with supervisors' representations. CONCLUSIONS: Our research suggests that clinical education and the identity positions available to teachers and learners were strongly influenced by the cultural worlds of individual specialties. Attempts to change work-based learning should be founded on situated knowledge of specialty-specific clinical workplace cultures and should be done in collaboration with the people who work there, the clinicians.

From fixer to facilitator: an interpretative phenomenological study of diabetes person-centred counselling and empowerment-based education.

Background: The purpose of this study is to explore the professional and personal experiences of multidisciplinary healthcare professionals during and following diabetes counselling and empowerment-based education. Methods: Everyone who had participated in a diabetes counselling and empowerment course between 2008-2016 was invited to respond to an online survey and follow-up telephone interview if willing. Interviews were recorded and transcribed verbatim. The research team used interpretative phenomenology to identify core themes from both the survey and telephone interviews and which captured the impact of empowerment-based education. Results: 22 doctors, nurses, dieticians, and psychologists completed an online questionnaire. 10 subsequently took part in telephone interviews. Empowerment-based education changed them from fixers to facilitators. Their transformation included a sense of becoming authentic, 'being the way I want to be' in clinical practice and becoming more self-reflective. This affected them personally as well as reinvigorating them professionally. Conclusions: The participants described a personal and professional journey of transformation that included discovering their person-centred philosophy. They adopted a consultation structure that empowered people with diabetes to care for themselves. It can be speculated that participants' experience of transformation may also guard against professional burnout.

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

PURPOSE: The hope that reliably testing clinicians' competencies would improve patient safety is unfulfilled and clinicians' psychosocial safety is deteriorating. Our purpose was to conceptualise 'mutual safety', which could increase benefit as well as reduce harm. METHODS: A cultural-historical analysis of how medical education has positioned the patient as an object of benefit guided implementation research into how mutual safety could be achieved. RESULTS: Educating doctors to abide by moral principles and use rigorous habits of mind and scientific technologies made medicine a profession. Doctors' complex attributes addressed patients' complex diseases and personal circumstances, from which doctors benefited too. The patient safety movement drove reforms, which reorientated medical education from complexity to simplicity: clinicians' competencies should be standardised and measurable, and clinicians whose 'incompetence' caused harm remediated. Applying simple standards to an increasingly complex, and therefore inescapably risky, practice could, however, explain clinicians' declining psychosocial health. We conducted a formative intervention to examine how 'acting wisely' could help clinicians benefit patients amidst complexity. We chose the everyday task of insulin therapy, where benefit and harm are precariously balanced. 247 students, doctors, and pharmacists used a thought tool to plan how best to perform this risky task, given their current clinical capabilities, and in the sometimes-hostile clinical milieus where they practised. Analysis of 1000 commitments to behaviour change and 600 learning points showed that addressing complexity called for a skills-set that defied standardisation. Clinicians gained confidence, intrinsic motivation, satisfaction, capability, and a sense of legitimacy from finding new ways of benefiting patients. CONCLUSION: Medical education needs urgently to acknowledge the complexity of practice and synergise doctors' and patients' safety. We have shown how this is possible.

How do children and adolescents experience healthcare professionals? Scoping review and interpretive synthesis.

OBJECTIVE: Explore children's and adolescents' (CADs') lived experiences of healthcare professionals (HCPs). DESIGN: Scoping review methodology provided a six-step framework to, first, identify and organise existing evidence. Interpretive phenomenology provided methodological principles for, second, an interpretive synthesis of the life worlds of CADs receiving healthcare, as represented by verbatim accounts of their experiences. DATA SOURCES: Five key databases (Ovid Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Web of Science), from inception through to January 2019, reference lists, and opportunistically identified publications. ELIGIBILITY CRITERIA: Research articles containing direct first-person quotations by CADs (aged 0-18 years inclusive) describing how they experienced HCPs. DATA EXTRACTION AND SYNTHESIS: Tabulation of study characteristics, contextual information, and verbatim extraction of all 'relevant' (as defined above) direct quotations. Analysis of basic scope of the evidence base. The research team worked reflexively and collaboratively to interpret the qualitative data and construct a synthesis of children's experiences. To consolidate and elaborate the interpretation, we held two focus groups with inpatient CADs in a children's hospital. RESULTS: 669 quotations from 99 studies described CADs' experiences of HCPs. Favourable experiences were of forming trusting relationships and being involved in healthcare discussions and decisions; less favourable experiences were of not relating to or being unable to trust HCPs and/or being excluded from conversations about them. HCPs fostered trusting relationships by being personable, wise, sincere and relatable. HCPs made CADs feel involved by including them in conversations, explaining medical information, and listening to CADs' wider needs and preferences. CONCLUSION: These findings strengthen the case for making CADs partners in healthcare despite their youth. We propose that a criterion for high-quality child-centred healthcare should be that HCPs communicate in ways that engender trust and involvement.

The pen is mightier than the sword. Reinstating patient care as the object of prescribing education.

Prescribing (writing medication orders) is one of residents' commonest tasks. Superficially, all they have to do is complete a form. Below this apparent simplicity, though, lies the complex task of framing patients' needs and navigating relationships with them and other clinicians. Mistakes, which compromise patient safety, commonly result. There is no evidence that competence-based education is preventing harm. We found a profound contradiction between medical students becoming competent, as defined by passing competence assessments, and becoming capable of safely caring for patients. We reinstated patients as the object of learning by allowing students to 'pre-prescribe' (complete, but not authorise prescriptions). This turned a disabling tension into a driver of curriculum improvement. Students 'knotworked' within interprofessional teams to the benefit of patients as well as themselves. Refocusing undergraduate medical education on patient care showed promise as a way of improving patient safety.

Uncovering the ecology of clinical education: a dramaturgical study of informal learning in clinical teams.

Off-the-job faculty development for clinical teachers has been blighted by poor attendance, unsatisfactory sustainability, and weak impact. The faculty development literature has attributed these problems to the marginalisation of the clinical teacher role in host institutions. By focusing on macro-organisational factors, faculty development is ignoring the how clinical teachers are shaped by their everyday participation in micro-organisations such as clinical teams. We set out to explore how the roles of clinical teacher and graduate learner are co-constructed in the context of everyday work in clinical teams. Using an ethnographic study design we carried out marginal participant observation of four different hospital clinical teams. We assembled a dataset comprising field notes, participant interviews, images, and video, which captured day-to-day working and learning encounters between team members. We applied the dramaturgical sensitising concepts of impression management and face work to a thematic analysis of the dataset. We found that learning in clinical teams was largely informal. Clinical teachers modelled, but rarely articulated, an implicit curriculum of norms, standards and expectations. Trainees sought to establish legitimacy and credibility for themselves by creating impressions of being able to recognise and reproduce lead clinicians' standards. Teachers and trainees colluded in using face work strategies to sustain favourable impressions but, in so doing, diminished learning opportunities and undermined educational dialogue. These finding suggest that there is a complex interrelationship between membership of clinical teams and clinical learning. The implication for faculty development is that it needs to move beyond its current emphasis on the structuring effects of institutional context to a deeper consideration of how teacher and learner roles are co-constructed in clinical teams.

Harnessing insights from an activity system - OSCEs past and present expanding future assessments.

Objective Structured Clinical Examinations (OSCEs) are a dominant, yet problematic, assessment tool across health professions education (HPE). OSCEs' standardised approach aligns with regulatory accountability, allowing learners to exchange exam success for the right to practice. We offer a sociohistorical account of OSCEs' development to support an interpretation of present assessment practices. OSCEs create tensions. Preparing for OSCE success diverts students away from the complexity of authentic clinical environments. Students will not qualify and will, therefore, be of no use to patients without getting marks providing evidence of competence. Performing in a formulaic and often non patient-centred way is the price to pay for a qualification. Acknowledging the stultifying effect of standardising human behaviour for OSCEs opens up possibilities to release latent energy for change in medical education. In this imagined future, the overall object of education is refocused on patient care.