The discursive context of medical aid in dying: A paradox of control?

Individual agency is central to late modern and neoliberal concepts of the self and notions of a good death. Assisted dying can be understood as a reflection of these ideas in that control over death resides with the individual. The aim of this article is to explore individual agency and control and employ concepts of biopower and freedom to illustrate the paradoxes inherent within assisted dying. Assisted dying is currently of wide interest due to legislative change. At the time of research, the New Zealand Parliament was passing the End of Life Choice Act, yet there had been no research with people approaching the end of life about assisted dying. Through the media we recruited and interviewed 14 people approaching the end of life who would have considered choosing assisted dying if it were available to them. Interviews were analyzed using an immersion/crystallization thematic analysis. Assisted dying appealed to participants because it offered control. This article examines the discursive context of control as well as the participants' perception of control to offer insights into how paradoxically, a medical regime of assisted dying reinforces health professionals as in control of the circumstances of dying. We argue that although legalized medical assisted dying is highly regulated and monitored, thus limiting freedom, the option of assisted dying also increases freedom for the dying person. Within this paradox of control, there is still scope for choice and an ethical making of the self, although limited by the biopolitical regime, that equates to a degree of freedom for participants.

Exploring the value of social network 'care maps' in the provision of long-term conditions care.

OBJECTIVES: There is renewed attention to the role of social networks as part of person-centred long-term conditions care. We sought to explore the benefits of 'care maps' - a patient-identified social network map of their care community - for health professionals in providing person-centred care. METHODS: We piloted care maps with 39 patients with long-term conditions in three urban and one rural general practice and two hospital wards. We interviewed the health professionals (n = 39) of these patients about what value, if any, care maps added to patient care. We analysed health professional interview data using thematic analysis to identify common themes. RESULTS: Health professionals all said they learned about their patients as a person-in-context. There was an increased understanding of patients' support networks, synthesising what is known and unknown. Health professionals understood patients' perceptions of health professionals and what really mattered to patients. There was discussion about the therapeutic value of care maps. The maps prompted reflection on practice. DISCUSSION: Care maps facilitated a broader focus than the clinical presentation. Using care maps may enable health professionals to support self-management rather than feeling responsible for many aspects of care. Care maps had 'social function' for health professionals. They may be a valuable tool for patients and clinicians to bridge the gap between medical treatment and patients' lifeworlds.

Communities of clinical practice in action: Doing whatever it takes.

Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient's well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients' medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice's repertoires are characterised by care and are driven by the moral imperative to care. They do 'whatever it takes', although there is a cost to this form of care. Well-functioning communities of clinical practice use patient's well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the 'messiness' of community-based care.

Moral Economy and Moral Capital in the Community of Clinical Practice.

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

Shared care requires a shared vision: communities of clinical practice in a primary care setting.

AIMS AND OBJECTIVES: To understand how a vision of care is formed and shared by patients and the primary care professionals involved in their care. BACKGROUND: To achieve the best health outcomes, it is important for patients and those who care for them to have a mutual understanding about what is important to the patient in their everyday life and why, and what care is necessary to realise this vision. Shared or team care does not necessarily translate to a consistent and integrated approach to a patient's care. An individual patient's care network of clinical and lay participants can be conceptualised as the patient's own 'Community of Clinical Practice' of which they are the central member. DESIGN: Working alongside a long-term conditions nursing team, we conducted a focused ethnography of nine 'Communities of Clinical Practice' in one general practice setting. METHOD: Participant observation, in-depth qualitative interviews with 24 participants including nine patients, and the patients' medical records. Data were analysed using a template organising style. FINDINGS: Primary care professionals' insight into a patient's vision of care evolves through a deep knowing of the patient over time; this is shared between 'Community of Clinical Practice' members, frequently through informal communication and realised through respectful dialogue. These common values - respect, authenticity, autonomy, compassion, trust, care ethics, holism - underpin the development of a shared vision of care. CONCLUSIONS: A patient's vision of care, if shared, provides a focus around which 'Community of Clinical Practice' members cohere. Nurses play an important role in sharing the patient's vision of care with other participants. RELEVANCE TO CLINICAL PRACTICE: A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a 'Community of Clinical Practice'.

The Safe and Effective Clinical Outcomes (SECO) clinic: learning responsibility for patient care through simulation.

BACKGROUND: This article describes a simulated General Practice clinic for medical students, which incorporates specific features to aid learning of clinical problem solving. DESCRIPTION: We outline the overall objectives of the simulation, explain the concept, and describe how the clinic works. The clinic is novel in that it utilises clinical outcomes as measures for student success in the consultation. There are no time restrictions on a consultation. Students are unobserved and have open access to clinical information and telephone advice from a senior colleague. EVALUATION: The achievement of the case-specific outcomes is assessed by reference to students' clinical notes and the responses of the simulated patients to specific scenario-related questions. Following the clinic there is a debrief session, and students are provided with the evidence base and outcomes for each scenario. CONCLUSIONS: The clinic has been part of our undergraduate curriculum since 2004. Collectively, students rate it as their most effective learning experience.

Joining the dots: conditional pass and programmatic assessment enhances recognition of problems with professionalism and factors hampering student progress.

BACKGROUND: Programmatic assessment that looks across a whole year may contribute to better decisions compared with those made from isolated assessments alone. The aim of this study is to describe and evaluate a programmatic system to handle student assessment results that is aligned not only with learning and remediation, but also with defensibility. The key components are standards based assessments, use of "Conditional Pass", and regular progress meetings. METHODS: The new assessment system is described. The evaluation is based on years 4-6 of a 6-year medical course. The types of concerns staff had about students were clustered into themes alongside any interventions and outcomes for the students concerned. The likelihoods of passing the year according to type of problem were compared before and after phasing in of the new assessment system. RESULTS: The new system was phased in over four years. In the fourth year of implementation 701 students had 3539 assessment results, of which 4.1% were Conditional Pass. More in-depth analysis for 1516 results available from 447 students revealed the odds ratio (95% confidence intervals) for failure was highest for students with problems identified in more than one part of the course (18.8 (7.7-46.2) p < 0.0001) or with problems with professionalism (17.2 (9.1-33.3) p < 0.0001). The odds ratio for failure was lowest for problems with assignments (0.7 (0.1-5.2) NS). Compared with the previous system, more students failed the year under the new system on the basis of performance during the year (20 or 4.5% compared with four or 1.1% under the previous system (p < 0.01)). CONCLUSIONS: The new system detects more students in difficulty and has resulted in less "failure to fail". The requirement to state conditions required to pass has contributed to a paper trail that should improve defensibility. Most importantly it has helped detect and act on some of the more difficult areas to assess such as professionalism.

Communities of clinical practice and normalising technologies of self: learning to fit in on the surgical ward.

This paper reports observational research of Fourth Year medical students in their first year of clinical training doing their surgical attachment. Previously, the authors have argued that medical curricula constitute normalising technologies of self that aim to create a certain kind of doctor. Here, they argue that a key mechanism through which these normalising technologies are exercised in the workplace is Etienne Wenger's communities of practice. In the clinical environment the authors identify communities of clinical practice (CoCP) as groups of health professionals that come together with the specific and common purpose of patient care. Fourth Year medical students join these transient communities as participants who are both peripheral and legitimate. Communities of clinical practice are potent vehicles for student learning. They learn and internalise the normative professional values and behaviours that they witness and experience within the disciplinary block of the medical school and teaching hospital; specifically, the authors suggest, it is through their participation in communities of clinical practice that medical students learn how to 'be one of us'.

Teaching and learning in the hospital ward.

AIM: To explore ways in which student learning during formal ward rounds can be enhanced. METHOD: Qualitative study of University of Otago medical students (Dunedin, New Zealand) involving observation of surgical teams during formal ward rounds, and indepth interviews with students and consultant surgeons. RESULTS: Teaching and learning opportunities on ward rounds were often missed by both clinical teachers and students as service provision and patient care took precedence. As a result, students often felt excluded and frequently expressed ambivalence about the educational value of formal whole team ward rounds. Students were more likely to consider themselves part of the team when they felt useful and were included in team discussions about patient care. They reported that they learned more effectively on smaller, more educationally focussed ward rounds that incorporated bedside tutorials and opportunities to practice examination skills. CONCLUSION: Students and clinical teachers know that students need to make the most of learning opportunities by being proactive, spending time on the ward, being useful, asking questions. Clinical staff can facilitate student learning by consciously including students in the business of patient care. This means inviting students to ask questions and examine wounds, physically guiding hands on examinations, encouraging students to pay attention to discussions among the clinical team, and explaining what is being discussed.

Communities of clinical practice: the social organization of clinical learning.

The social organization of clinical learning is under-theorized in the sociological literature on the social organization of health care. Professional scopes of practice and jurisdictions are formally defined by professional principles and standards and reflected in legislation; however, these are mediated through the day-to-day clinical activities of social groupings of clinical teams. The activities of health service providers typically occur within communities of clinical practice. These are also major sites for clinical curriculum delivery, where clinical students learn not only clinical skills but also how to be health professionals. In this article, we apply Wenger's model of social learning within organizations to curriculum delivery within a health service setting. Here, social participation is the basis of learning. We suggest that it offers a powerful framework for recognizing and explaining paradox and incongruence in clinical teaching and learning, and also for recognizing opportunities, and devising means, to add value to students' learning experiences.

For better or worse: role models for New Zealand house officers.

Role modelling is considered an important influence on emerging professional identity. However as a process it goes largely uninspected. In an effort to develop greater awareness of this important process, this study examines the positive and negative role modelling experiences of New Zealand house officers.

General practitioners' attitudes toward (and use of) complementary and alternative medicine: a New Zealand nationwide survey.

AIMS: This study aimed to update our understanding of how general practitioners view and use complementary and alternative medicine (CAM). METHOD: A nationwide cross-sectional postal questionnaire sent to 500 randomly selected general practitioners (GPs) of the 2358 who met the inclusion criteria of the study in December 2005. RESULTS: 300 completed questionnaires were returned thus giving a response rate of 60%. Twenty percent of the GP respondents practiced (and 95% referred patients to) one or more forms of complementary and alternative medicine. The most common CAM therapy practiced by GPs was acupuncture, and chiropractic manipulation was the most common GP-referred therapy for patients. Thirty-two percent of respondents had formal training and 29% had self education in one or more CAM therapies. Sixty-seven percent felt that an overview of CAM should be included in conventional medical education. CONCLUSIONS: The number of GPs practising CAM therapies has decreased over the past 15 years, although the number referring patients to CAM has increased. The finding 'that GPs feel information about CAM should be included in medical education' is consistent with earlier research and should be taken into account when developing the medical curriculum.

'Do as I say, not as I do': Medical Education and Foucault's Normalizing Technologies of Self.

Medical training as a process of professional socialization has been well explored within the fields of medical education, medical sociology and medical anthropology. Our contribution is to outline a bio-power, more specifically an anatomo-politics, of medical education. The current research aimed to explore perspectives on what is commonly termed the 'hidden curriculum'. We conducted interviews with pre-clinical medical students, clinical teachers and medical educators within a New Zealand medical school. In this paper, we outline ways that respondents described the juxtaposition of the undeclared or hidden aspects of medical education with the formal declared curriculum. Our respondents were aware of incongruencies across these components that resulted in mixed messages to students. Curricula initiatives aim to encourage new forms of subjectivity so that students are often expected to be the kinds of doctors that their teachers are not. However, the success of such initiatives is dependent on the degree of alignment between informal and formal components of the curriculum.

Objectivity in objective structured clinical examinations: checklists are no substitute for examiner commitment.

PURPOSE: This study explored factors that contribute to objectivity in objective structured clinical examinations (OSCEs). The authors quantified the effect of examiners on interrater reliability and separated this effect from that of station construction, determined the effect of objectification on station reliability and validity, and explored examiner factors that may contribute to interrater reliability. METHOD: Data came from examiners' mark sheets from four annual OSCEs (1997-2000). The OSCEs were conducted identically and simultaneously at three sites, within the University of Otago medical school in New Zealand, with two examiners at each station. The contribution to interrater correlations of station construction and mark sheet compared with examiners' contribution was partitioned out using a random-effects analysis of variance. For one OSCE, a multiple linear regression was used to determine the independent contributions to interrater reliability of the number of checklist items per mark sheet, examiner experience, and examiner involvement in station construction. RESULTS: Station construction and mark sheets contributed 10.1% and examiners contributed 89.9% to the variation in interrater reliability. Following multivariate analysis, the number of items per mark sheet was negatively associated, and examiner involvement in station construction was positively associated, with interrater reliability. Examiner experience in examining or in clinical medicine was not associated with interrater reliability. There was a negative, but nonsignificant, correlation between number of items per mark sheet and that station's correlation with the aggregate OSCE mark. CONCLUSIONS: The contribution of objective mark sheets to objectivity is relatively minor compared with examiners' contribution. Increasing the number of checklist items per mark sheet decreased both reliability and validity. Achieving objectivity requires diligent examiners who are involved in the whole assessment.

Was a breach of examination security unfair in an objective structured clinical examination? A critical incident.

One-third of a class of students was inadvertently given the names of stations immediately prior to an OSCE and two-thirds of the class were not. This provided an opportunity to explore student perceptions of fairness and to explore any effect of this cueing. The subjects were medical students undertaking an end of fifth year multidisciplinary OSCE. OSCE score data from the 20 students who had received the information were compared with those of the 40 students who did not. We also compared their performance on other assessments to determine whether the two groups were comparable. The overall OSCE mark was not significantly different between the two groups. There were significant differences between groups on four stations but this was not in a consistent direction that advantaged one group. There were no significant differences between the two groups in their performance on the other examinations. This inadvertent security breach had no systematic effect on student OSCE station scores. This incident provided a valuable opportunity to admit error, approach it rationally and restore any resulting breach of trust.