Transformative Leadership Training in Medical Education: A Topology.

Issue: Efforts to improve medical education often focus on optimizing technical aspects of teaching and learning. However, without considering the connection between the pedagogical-curricular and the foundational philosophically-defined educational aims of medicine and medical education, critical system reform is unlikely. The transformation of medical education requires leaders uniquely prepared to view medicine and medical education critically as it is and as it ought to be, and who have the capacity to lead changes aimed at overcoming the identified gaps. This paper proposes a five-level topology to guide leaders to develop this capacity. Evidence: Without reference to a shared understanding of a larger, more profound philosophical vision of the ideal physician and of the educational process of "becoming" that physician, efforts to change medical education are likely to be incremental and insufficient rather than transformative. Such efforts may lead to frequent pedagogical-curricular reforms, shifting evaluation models, and paradigmatic conflicts in medical education systems across contexts. This paper describes a leadership program meant to develop transformational educational leaders. The leadership program is built on and teaches the five-level topology we describe here. The five levels are 1) Philosophy 2) Philosophy of Education 3) Theory of Practice 4) Implementation and 5) Evaluation. Implications: The leadership development program exemplifies how the topology can be implemented as a framework to foster transformation in medical education. The topology is a metaphor exemplified by the Mobius Strip, a continuous and never-broken object, which reflects the ways in which the five levels are inherently connected and reflect on each other. Medical education leadership requires deeper engagement with paradigmatic thought to transform the field for the future.

Position paper: Teaching breaking bad news (BBN) to undergraduate medical students.

Sharing new medical information that is perceived as seriously effecting people's lives, i.e., breaking bad news (BBN) is important in caring for patients and relatives and is challenging for healthcare professionals. Optimal BBN requires incorporation and implementation of multiple professional competencies acquired gradually throughout years of training. The BBN encounter has implications for all participants: the patient, family members, their close social environments, and the deliverer of the news. Due to these implications and the accountability involved, medical schools invest educational resources in helping medical students develop this competency. The current paper summarizes literature, research, and teaching experiences while suggesting practical guidelines for designing and teaching a BBN course to undergraduate students. The following principles lie behind the recommendations: stepwise spiral continuity of exposure to and teaching of communication skills in various contexts while focusing on BBN in the advanced clinical years; relating the developing skills to broader humanistic studies; enhancing awareness of self-perspectives and beliefs regarding BBN; connecting to patients' and family members experiences and needs; providing a BBN protocol and opportunities for structured experiential learning followed by reflection and feedback; using observation and reflection to address gaps between theory and real-life practice; and creating continuity of learning about BBN through undergraduate, graduate, and continuing medical education. Applying this learning process can help enhance the management of these difficult conversations to improve patients' care during these difficult, life-changing encounters, and physicians' well-being.

Twelve tips to manage a breaking bad news process: Using S-P-w-ICE-S - A revised version of the SPIKES protocol.

Breaking bad news (BBN) is a difficult task that requires multiple professional competencies. The way it is managed has implications for all involved in the encounter: the patient, family members, and the news provider. Existing guidelines were developed mainly at the turn of the millennium and require updating based on identification of daily clinical needs and pedagogical challenges while teaching the current protocols. Furthermore, there is a need to provide an overview of BBN encounters as a process, rather than a subdivided event, to help practitioners adopt an approach that might serve them in their daily routines. This twelve tips article summarizes research and practical experience for handling BBN encounters, from their preparation, through delivering the news while attending patients and family members' needs, toward documenting the news, and critically reflecting on the interaction. The tips are structured and explained to serve both practitioners and medical educators.

Can doctors be taught virtue?

Medical schools and residency programs have become very adept at teaching medical students and residents an enormous amount of information. However, it is much less clear whether they are effective at fostering virtuous qualities like empathy or professionalism in trainees. This would come as no surprise to Plato, who famously argued in the Meno that virtue cannot be taught. This pedagogical challenge threatens to stymie medical educators, who increasingly recognize the importance of professionalism, compassion, and empathy in the practice of good medicine. As medical educators, we are motivated to demonstrate that virtue is teachable and to find a way to do so, as this is how we will be able to improve the conduct of physicians and the quality of their care of patients. As such, we address the question of the teachability of virtue in the realm of medicine, analysing Plato's contradictory analyses in the Meno and Protagoras, and drawing upon modern neuroscience to turn an empirical lens on the question. We explore the ways in which Noddings' Ethic of Care may offer a way forward for medical educators keen to foster virtue in trainees. We conclude by demonstrating how, by harnessing the power of caring relationships, the principles of Noddings' Ethic of Care have already been applied to medical education at a university in Israel.

Medical students' experiences and needs from written reflective journal feedback.

INTRODUCTION: Reflective ability is an important skill for enhancing professionalism and developing communication skills. To improve reflective ability, medical educators encourage use of written reflective journals, for which feedback is important. It is difficult for educators to anticipate how their feedback will be perceived. Therefore, this study examined students' experiences with educators' written feedback on reflective journals. METHODS: A qualitative, immersion/crystallization analysis of 60 written feedback texts to 15 medical students (30 identified by students as meaningful and 30 as less meaningful) and in-depth semi-structured interviews with these students. We did not define 'meaningful', to leave room for students' own interpretations. We analysed the feedback to identify what it includes (its components) and analysed the interviews to learn about students' experiences of receiving the feedback and the specific components. RESULTS: Students experienced five components as meaningful: supportive and encouraging statements; legitimisation of their emotions; educators sharing personal-professional experiences; asking questions to enhance reflection; and focusing on the students' main concern. These components enhanced students' willingness to read and learn from the feedback. Three components were experienced as less meaningful: detached, impersonal feedback; negative tone (criticism); and technical issues, for example brevity. These disappointing and hurtful components led students to pay less attention to the feedback or to invest less effort in future written assignments. CONCLUSIONS: The present study identified components in written reflective journal feedback texts and the experience and needs of students who received them. It showed the complexity of writing reflective feedback because of the need to support students through it, help them deal with emotions, identify and focus on personal content that matters to them, and provide opportunities to develop and enhance their reflective ability, while being mindful of their emotional state. To help educators in this challenging task, a self-assessment mnemonic ('FEEDBACK') for use before sending the initial feedback was developed.

The associations between reflective ability and communication skills among medical students.

OBJECTIVES: Assess associations between medical students' reflective ability demonstrated in written narratives, and communication skills demonstrated later in simulated-patient breaking bad news interactions. METHODS: We analyzed 66 medical students' reflective ability, using 'REFLECT' rubric and four newly developed parameters: Noticing Explanations provided to patients, Noticing Emotions, Remoteness/Connectedness in their writing, and mentioning Self-Emotions. 'BAS' and 'SPIKES' questionnaires measured students' communication skills. Spearman and Chi-square tests examined correlations among all variables. Multiple regressions examined associations between reflective ability and demographic variables with communication skills. RESULTS: Significant positive correlations between students' reflective ability, measured by REFLECT and three of the new parameters, and global communication skill scores. Reflective ability of Noticing Explanations in writing was associated with ability to tailoring information to patients' needs and address emotions. CONCLUSIONS: High reflective ability may improve communication skills. Specifically, ability to notice explanations to patients may enhance later capability to tailor information to patients and address emotions empathically. PRACTICE IMPLICATIONS: Encourage educational interventions enhancing reflective ability; specifically observation and detailed writing about how explanations are given to patients and patients' reactions to them. This process may help students develop competency to share and tailor difficult information sensitively-a critical skill when communicating bad news.

What you "see" is how you communicate: Medical students' meaning making of a patient's vignette.

OBJECTIVES: To examine how medical students notice issues in a vignette and construct their meaning, and how this construction influences their plan to communicate with the patient. METHODS: Following a breaking bad news course for 112 senior medical students, we qualitatively analyzed the participants' written descriptions of the issues they noticed as requiring special attention, using an Immersion/Crystallization iterative consensus process. RESULTS: Different students noticed different issues, but no-one noticed all 19 planted issues (Mean of issues noticed by students = 6.77; SD = 2.29). The students wrote about the issues in 46 different ways, representing the diverse meanings they ascribed, ranging from identifying, through inferring, to interpreting while jumping to conclusions. Moreover, for some issues, some students focused on the patient whereas others focused on the physician or the physician-patient relationship. Noticing issues led to preparing for communication with the patient. CONCLUSIONS: Noticing the issues and the subsequent meaning-making process facilitated the preparation to address them in the envisioned encounter. PRACTICE IMPLICATIONS: When teaching communication skills, it would be helpful to focus on increasing students' awareness of the issues they notice or fail to notice and their personal meaning-making process. This might reduce bias and enhance their preparation for effective patient-centered communication.

See, reflect, learn more: qualitative analysis of breaking bad news reflective narratives.

CONTEXT: Breaking bad news (BBN) is a challenge that requires multiple professional competencies. BBN teaching often includes didactic and group role-playing sessions. Both are useful and important, but exclude another critical component of students' learning: day-to-day role-model observation in the clinics. Given the importance of observation and the potential benefit of reflective writing in teaching, we have incorporated reflective writing into our BBN course. The aim of this study was to enhance our understanding of the learning potential in reflective writing about BBN encounters and the ability to identify components that inhibit this learning. METHODS: This was a systematic qualitative immersion/crystallization analysis of 166 randomly selected BBN narratives written by 83 senior medical students. We analysed the narratives in an iterative consensus-building process to identify the issues discussed, the lessons learned and the enhanced understanding of BBN. RESULTS: Having previously been unaware of, not invited to or having avoided BBN encounters, the mandatory assignment led students to search for or ask their mentors to join them in BBN encounters. Observation and reflective writing enhanced students' awareness that 'bad news' is relative and subjective, while shedding light on patients', families', physicians' and their own experiences and needs, revealing the importance of the different components of the BBN protocol. We identified diversity among the narratives and the extent of students' learning. DISCUSSION: Narrative writing provided students with an opportunity for a deliberative learning process. This led to deeper understanding of BBN encounters, of how to apply the newly taught protocol, or of the need for it. This process connected the formal and informal or hidden curricula. To maximise learning through reflective writing, students should be encouraged to write in detail about a recent observed encounter, analyse it according to the protocol, address different participants' behaviours and emotions, and identify dilemmas and clear lessons learned.

Medical education in Israel 2016: five medical schools in a period of transition.

ABSTRACT: We reviewed the existing programs for basic medical education (BME) in Israel as well as their output, since they are in a phase of reassessment and transition. The transition has been informed, in part, by evaluation in 2014 by an International Review Committee (IRC). The review is followed by an analysis of its implications as well as the emergent roadmap for the future. The review documents a trend of modernizing, humanizing, and professionalizing Israeli medical education in general, and BME in particular, independently in each of the medical schools. Suggested improvements include an increased emphasis on interactive learner-centered rather than frontal teaching formats, clinical simulation, interprofessional training, and establishment of a national medical training forum for faculty development. In addition, collaboration should be enhanced between medical educators and health care providers, and among the medical schools themselves. The five schools admitted about 730 Israeli students in 2015, doubling admissions from 2000. In 2014, the number of new licenses, including those awarded to Israeli international medical graduates (IMGs), surpassed for the first time in more than a decade the estimated need for 1100 new physicians annually. About 60 % of the licenses awarded in 2015 were to IMGs. CONCLUSIONS: Israeli BME is undergoing continuous positive changes, was supplied with a roadmap for even further improvement by the IRC, and has doubled its output of graduates. The numbers of both Israeli graduates and IMGs are higher than estimated previously and may address the historically projected physician shortage. However, it is not clear whether the majority of newly licensed physicians, who were trained abroad, have benefited from similar recent improvements in medical education similar to those benefiting graduates of the Israeli medical schools, nor is it certain that they will benefit from the further improvements that have recently been recommended for the Israeli medical schools. Inspired by the IRC report, this overview of programs and the updated physician manpower data, we hope the synergy between all stakeholders is enhanced to address the combined medical education quality enhancement and output challenge.

The role of medical schools in promoting social accountability through shared decision-making.

Reducing health inequalities and enhancing the social accountability of medical students and physicians is a challenge acknowledged by medical educators and professionals. It is usually perceived as a macro-level, community type intervention. This commentary suggests a different approach, an interpersonal way to decrease inequality and asymmetry in power relations to improve medical decisions and care. Shared decision-making practices are suggested as a model that requires building partnership, bi-directional sharing of information, empowering patients and enhancing tailored health care decisions. To increase the implementation of shared decision-making practices in Israel, an official policy needs to be established to encourage the investment of resources towards helping educators, researchers, and practitioners translate and integrate it into daily practice. Special efforts should be invested in medical education initiatives to train medical students and residents in SDM practices.

The impact of senior medical students' personal difficulties on their communication patterns in breaking bad news.

PURPOSE: To evaluate the possible influence of personal difficulties and barriers that are within the news bearer and his or her self-awareness (SA) of them, on the patterns of communication during encounters involving breaking bad news (BBN). METHOD: Following an intensive BBN course in 2004, 103 senior medical students at the Sackler School of Medicine, Tel Aviv University, were evaluated for BBN competencies by the analysis of their written descriptions of how they visualized their manner of delivering bad news to a patient described in a challenging vignette. The students were further asked to reflect on their own difficulties and barriers that surfaced in response to reading the narrative presented in the vignette and in delivering the bad news. Using an immersion crystallization narrative analysis method, the authors analyzed the relationship between the students' BBN strategies and their self-perceived barriers and difficulties. RESULTS: Four types of communicators were identified and related to 45 different personal and professional barriers that the students, through self-reflection, found in themselves. These perceived barriers as well as the ability to self-reflect on them influenced their patterns of communication in their envisioned and written-down encounters, including the level of emotional connectedness, information provided, and the chosen focus-of-care paradigm (physician-centered, patient-centered, or relationship-centered). CONCLUSIONS: These findings empirically demonstrate that intrapersonal difficulties within the communicator and his or her level of SA about them influenced the manner and content of the communication during the encounter. This finding suggests that enhancing SA and addressing personal and professional difficulties could help physicians' capability to cope with challenging communication tasks. The authors propose a working tool (the Preparatory SPIKES) to facilitate the integration of self-reflection (by identifying personal difficulties) into day-by-day planning and delivery of bad news.

Interphase fluorescence in situ hybridization detection of chromosome 17 and 17q region gains in neuroblastoma: are they secondary events?

Gains of chromosome 17 and 17q region are the most frequent chromosomal abnormalities in neuroblastoma and have been associated with established prognostic indicators. Interphase fluorescence in situ hybridization (FISH) was used to define the status of chromosome 17 in near-triploid (3n) and near-diploid/tetraploid (2n/4n) primary tumors. Gains of chromosome 17 and 17q were detected in 22 and 26 tumors, respectively, in which the ploidy status was determined mainly by the copy number of chromosome 1. Four different types of gains were detected: gain of whole chromosome 17 (+17) and three partial gains (17q11.2 approximately qter, 17q21.1 approximately qter, and 17q21.3 approximately qter). The 17q11.2 approximately qter gains were found in both the 2n/4n and the 3n tumors. Gains of 17q21.1 approximately qter and 17q21.3 approximately qter were found only in the 2n/4n group, and the latter was involved always as a der(22)t(17;22)(q21;q13). A high association was found between chromosome 17 gains and 3n ploidy: +17 was detected in 93% of the 3n group and was not observed in the 2n/4n group. The +17 clone or clones were always present in combination with a clone with normal copies of chromosome 17 and, in the majority, with a +17q11.2 approximately qter clone. We conclude that interphase FISH is a sensitive method for detecting whole and partial chromosome 17 gains in neuroblastoma and can demonstrate the simultaneous presence of several clones with different status of chromosome 17 in 3n neuroblastomas. We suggest that chromosome 17 and 17q gains are not a primary event in the development of neuroblastoma.