Challenges for Family Medicine Residents in Attaining the CanMEDS Professional Role: A Thematic Analysis of Preceptor Field Notes.

PURPOSE: Among the roles of the competent physician is that of a professional, according to the Canadian Medical Education Directives for Specialists (CanMEDS) framework, which describes the abilities physicians require to effectively meet the health care needs of the people they serve. Through examination of preceptor field notes on resident performance, the authors identified aspects of this role with which family medicine residents struggle. METHOD: The authors used a structured thematic analysis in this qualitative study to explore the written feedback postgraduate medical learners receive at the University of Toronto Department of Family and Community Medicine. Seventy field notes written between 2015 and 2017 by clinical educators for residents who scored "below expectation" in the CanMEDS professional role were analyzed. From free-text comments, the authors derived inductive codes, amalgamated the codes into themes, and measured the frequency of the occurrence of the codes. The authors then mapped the themes to the key competencies of the CanMEDS professional role. RESULTS: From the field notes, 7 themes emerged that described reasons for poor performance. Lack of collegiality, failure to adhere to standards of practice or legal guidelines, and lack of reflection or self-learning were identified as major issues. Other themes were failure to maintain boundaries, taking actions that could have a negative impact on patient care, failure to maintain patient confidentiality, and failure to engage in self-care. When the themes were mapped to the key competencies in the CanMEDS professional role, most related to the competency "commitment to the profession." CONCLUSIONS: This study highlights aspects of professional conduct with which residents struggle and suggests that the way professionalism is taught in residency programs-and at all medical training levels-should be reassessed. Educational interventions that emphasize learners' commitment to the profession could enhance the development of more practitioners who are consummate professionals.

Postgraduate Assessment Approaches Across Surgical Specialties: A Systematic Review of the Published Evidence.

PURPOSE: Ensuring competence for surgical trainees requires holistic assessment of the qualities and competencies necessary to practice safely and effectively. To determine the next steps toward achieving this aim, the authors conducted a systematic review to summarize and appraise the available evidence related to any assessment approach to postgraduate surgical training and to identify the dominant themes for assessment approaches across different specialties or countries. METHOD: Medline and Embase were searched on January 10, 2019, without language or time restrictions. Any peer-reviewed study that described an assessment framework (in practice or novel) throughout postgraduate surgical training globally was included. An iterative review and thematic analysis were performed on full-text articles to determine assessment themes. Studies were then grouped by assessment themes. A tailored quality assessment of the studies included in the final analysis was conducted. Assessment themes and validity were compared across surgical specialties and countries. RESULTS: From an initial 7,059 articles, 91 studies (evaluating 6,563 surgical trainees) were included in the final analysis. Ten defined assessment themes were extracted. Ten studies (11.0%) were deemed low risk of bias based on the quality assessment tool used and thus were determined to be high quality. Minor differences in assessment themes were observed between specialties and countries. Assessment themes neglected by individual surgical specialties and assessment themes that need validated assessment tools were identified. CONCLUSIONS: This review highlights the low quality of evidence and fragmented efforts to develop and optimize surgical assessments. The minor differences observed demonstrate a common approach, globally and across specialties, related to surgical assessments. A paradigm shift in assessment approaches, which will require national and international collaboration, is required to optimize design and validation so that a comprehensive assessment of surgical competence can be implemented.

Low- and Middle-Income Country Host Perceptions of Short-Term Experiences in Global Health: A Systematic Review.

PURPOSE: Stakeholders have expressed concerns regarding the impact of visiting trainees and physicians from high-income countries (HICs) providing education and/or short-term clinical care in low- and middle-income countries (LMICs). This systematic review aimed to summarize LMIC host perceptions of visiting trainees and physicians from HICs during short-term experiences in global health (STEGH). METHOD: In September 2018 then again in August 2020, the authors searched 7 databases (PubMed, Embase, Scopus, Web of Science, ERIC, Cochrane Library, Global Index Medicus) for peer-reviewed studies that described LMIC host perceptions of STEGH. They extracted information pertaining to study design, participant demographics, participant perceptions, representation of LMICs and HICs, and HIC visitors' roles and used thematic synthesis to code the text, develop descriptive themes, and generate analytical themes. RESULTS: Of the 4,020 studies identified, 17 met the inclusion criteria. In total, the studies included 448 participants, of which 395 (88%) represented LMICs. The authors identified and organized 42 codes under 8 descriptive themes. They further organized these descriptive themes into 4 analytical themes related to STEGH: (1) sociocultural and contextual differences, (2) institutional and programmatic components, (3) impact on host institutions and individuals, and (4) visitor characteristics and conduct. CONCLUSIONS: STEGH can have both beneficial and detrimental effects on LMIC host institutions and individuals. The authors translated these findings into a set of evidence-based best practices for STEGH that provide specific guidance for LMIC and HIC stakeholders. Moving forward, LMIC and HIC institutions must work together to focus on the quality of their relationships and create conditions in which all stakeholders feel empowered to openly communicate to ensure equity and mutual benefit for all parties.

Partnerships between universities and nonprofit transition coaching organizations to increase student success.

AIMS: This study aims to understand the motivations and benefits for universities and nonprofit college access and success organizations to develop formal partnerships. METHODS: Participants in this study were staff from a major urban research university (n = 22) and four nonprofit organizations (n = 17) that promote college access and success among underrepresented, low-income, and first-generation college students. Participants engaged in an audio-recorded interview that was transcribed and analyzed using thematic analysis. RESULTS: Data suggested that staff from the universities and nonprofit organizations were both holistic in their understanding of college student success. In addition, they were both motivated to form partnerships in an effort to reduce barriers to success, although they, at times, identified different barriers that they wanted the partnership to address. Both university and nonprofit staff saw increased effectiveness of their practice as a result of partnering and university staff gained a better understanding of the greater nonprofit college access and success community. CONCLUSION: Given the intense support that nonprofit organizations are able to provide with their level of funding, partnerships with universities can increase the success of underrepresented, low-income, and first-generation college students.

Social suffering and the psychological impact of structural violence and economic oppression in an ongoing conflict setting: The Gaza Strip.

Structural violence and economic oppression (e.g. control over resources, politically engineered poverty and unemployment) are common features of warfare, yet there is a lack of research exploring the impact this has on civilian wellbeing in conflict-affected areas. This study, embedded within a human rights and community liberation psychology framework, aims to address this need by studying young Palestinian university graduates living under military blockade and occupation in the Gaza Strip. Semi-structured interviews were conducted. Thematic analysis indicated that economic and political domains adversely affected multiple aspects of civilian life and wellbeing. The findings revealed the deleterious effects of structural violence and economic oppression which created: human insecurity; poor psychological wellbeing and quality of life; existential, psychological and social suffering; humiliation; injuries to dignity; multiple losses; and led to life being experienced as 'on hold'. Local expressions and idioms to express distress were identified. The findings contributed to unique insights regarding how continual, systemic, and structural oppression can be potentially more psychologically detrimental than specific incidents of conflict and violence. The implications and the relevance of the findings to mental health and disaster relief are considered. Interventions providing human security and economic security should be prioritised.

Understanding the impact of an after-school music program with engaged underserved youth.

AIMS: This study aims to document and understand the benefits of underserved youths' successful involvement in an after-school music program (ASMP). METHODS: The contents of semi-structured, individual interviews with 11 alumni and five staff members of an ASMP were coded and analyzed using inductive Thematic Analysis. RESULTS: Alumni identified several positive program characteristics as most influential (e.g., consistency, opportunity, exposure), and described the program's favorable impact at a personal (e.g., identity development), relational (e.g., improving social skills), and musical level (e.g., acquiring performance skills). Staff members identified similar program characteristics as crucial for the success of the program and singled out their personal, relational, and social motivations as important dimensions that bring about the program's impact. CONCLUSIONS: The study highlights the value of musical experiences and after-school resources for a group of underserved youth who would otherwise not be exposed to them due to socioeconomic barriers and inequities in opportunities.

Psychological Assessment Training in Clinical Psychology Doctoral Programs.

We surveyed American Psychological Association-accredited clinical psychology doctoral programs' (n = 83) training in psychological assessment-specifically, their coverage of various assessment topics and tests in courses and practica, and whether the training was optional or required. We report results overall and separately per training model (clinical science, scientist-practitioner, and practitioner-focused). Overall, our results suggest that psychological assessment training is as active, or even more active, than in previous years. Areas of increased emphasis include clinical interviewing and psychometrics; multimethod, outcomes, health, and collaborative or therapeutic assessment; and different types of cognitive and self-report personality tests. All or almost all practice-focused programs offered training with the Thematic Apperception Test and Rorschach compared to about half of the scientist-practitioner programs and a third of the clinical science programs. Although almost all programs reported teaching multimethod assessment, what constitutes different methods of assessing psychopathology should be clarified in future studies because many programs appear to rely on one method-self-report (especially clinical science programs). Although doctoral programs covered many assessment topics and tests in didactic courses, there appears to be a shortage of program-run opportunities for students to obtain applied assessment training. Finally, we encourage doctoral programs to be familiar with (a) internships' assessment expectations and opportunities, (b) the professional guidelines for assessment training, and

Functioning in the Real World: Using Storytelling to Improve Validity in the Assessment of Executive Functions.

Real-world contexts differ in the clarity of expectations for desired responses, as do assessment procedures, ranging along a continuum from maximal conditions that provide well-defined expectations to typical conditions that provide ill-defined expectations. Executive functions guide effective social interactions, but relations between them have not been studied with measures that are matched in the clarity of response expectations. In predicting teacher-rated social competence (SC) from kindergarteners' performance on tasks of executive functions (EFs), we found better model-data fit indexes when both measures were similar in the clarity of response expectations for the child. The maximal EF measure, the Developmental Neuropsychological Assessment, presents well-defined response expectations, and the typical EF measure, 5 scales from the Thematic Apperception Test (TAT), presents ill-defined response expectations (i.e., Abstraction, Perceptual Integration, Cognitive-Experiential Integration, and Associative Thinking). To assess SC under maximal and typical conditions, we used 2 teacher-rated questionnaires, with items, respectively, that emphasize well-defined and ill-defined expectations: the Behavior Rating Inventory: Behavioral Regulation Index and the Social Skills Improvement System: Social Competence Scale. Findings suggest that matching clarity of expectations improves generalization across measures and highlight the usefulness of the TAT to measure EF.

Breastfeeding beliefs and practices of African women living in Brisbane and Perth, Australia.

The purpose of this study was to explore the experience of breastfeeding among refugee women from Liberia, Sierra Leone, Burundi and the Democratic Republic of Congo living in two major capital cities in Australia. Participants were recruited from their relevant community associations and via a snowballing technique. Thirty-one women took part in either individual interviews or facilitated group discussions to explore their experiences of breastfeeding in their home country and in Australia. Thematic analysis revealed four main themes: cultural breastfeeding beliefs and practices; stigma and shame around breastfeeding in public; ambivalence towards breastfeeding and breastfeeding support. Women who originated from these four African countries highlighted a significant desire for breastfeeding and an understanding that it was the best method for feeding their infants. Their breastfeeding practices in Australia were a combination of practices maintained from their countries of origin and those adopted according to Australian cultural norms. They exemplified the complexity of breastfeeding behaviour and the relationship between infant feeding with economic status and the perceived social norms of the host country. The results illustrate the need for policy makers and health professionals to take into consideration the environmental, social and cultural contexts of the women who are purportedly targeted for the promotion of breastfeeding.

Avaliação do funcionamento cognitivo por meio do CAT-A: evidências de validade / Cognitive assessment using the CAT-A: validity evidence

O objetivo desse estudo foi trazer evidências de validade do CAT-A para avaliação do funcionamento cognitivo em crianças. Correlacionou-se indicadores cognitivos no CAT-A; DFH e Rorschach no Sistema Compreensivo. Inicialmente, com base no DFH, selecionou-se 46 crianças de 7 e de 12 anos, divididas em dois grupos, um com 32 participantes com nível cognitivo abaixo do esperado e outro com 14 com nível acima do esperado. Em seguida aplicou-se o Rorschach e o CAT-A, individualmente. Os índices de correlação significativa entre os instrumentos permitiram encontrar evidências de validade para o CAT-A na avaliação da cognição. Quanto aos indicadores que avaliam o nível de desenvolvimento da percepção no CAT-A, obteve-se diferenças de média entre os dois grupos, cognição elevada e cognição abaixo do esperado para idade, denotando convergência entre os resultados das três técnicas. Os resultados não apenas trouxeram um avanço para o uso do CAT-A como também abrem novas perspectivas de pesquisas com esse instrumento.

The aim of this study was to verify the validity of the Children Apperception Test (CAT-A) for cognitive assessment of children. The results of CAT-A were correlated with Human Figure Drawing (HFD) and the Rorschach Method. Based on the data of HFD, the sample was composed of 46 children: 32 with low scores and 14 with a higher level of cognition. The Rorschach and the CAT-A were administered individually. The rates of significant correlation between the instruments pointed out for validity evidence for the CAT-A in the assessment of cognition. As for indicators that assess the development level of perception in the CAT-A, it was found some differences between the two groups, denoting convergence between the results of HFD and CAT-A. Thus, the significant correlation of the CAT-A and the two other instruments is an evidence of validity to CAT-A to assess cognitive aspects and allow some advances for its use and for further researches using this technique.

Avaliação psicológica no adolescente: objeto de mediação terapêutica / Psychological assessment in teen: object of therapy mediation / Evaluación psicológica en el adolescente: objeto de mediación terapéutica

Referindo-se aos trabalhos de autores franceses antigos e atuais que contribuíram para a reabilitação da avaliação psicológica na prática clínica, este texto focaliza o interesse da avaliação psicológica de orientação psicanalítica como objeto de mediação com fins terapêuticos. Ele tenta mostrar, apoiado em uma ilustração clínica de uma avaliação psicológica de uma adolescente de 16 anos, de que modo a utilização da avaliação pode se inscrever em uma abordagem global de tratamento do sujeito.

Referring to the work of former and current French authors who contributed to the reinstatement of psychological assessment in clinical practice, this text focuses the interest of psychological assessment of psychoanalytic orientation as an object of mediation with therapeutic aims. Supported by a clinical illustration of a psychological assessment of a 16-year-old adolescent, it means to show how the use of the assessment can be inserted into a global approach for treating the subject.

Con base en trabajos de autores franceses antiguos y actuales que han contribuido a la rehabilitación de la evaluación psicológica en la práctica clínica, este texto enfoca el interés de la evaluación psicológica de orientación psicoanalítica como objeto de mediación con fines terapéuticos. El estudio busca mostrar, con el respaldo de una ilustración clínica de la evaluación psicológica de una adolescente de 16 años de edad, de qué manera el uso de la evaluación puede inscribirse en un abordaje global de tratamiento del sujeto.

The assessment of the social cognition and object relations scale on TAT and interview data.

This study examines the reliability and convergent validity of 2 versions of the Social Cognition and Object Relations Scale (SCORS), one for use with Thematic Apperception Test narratives (SCORS-TAT; Westen, 1990) and one for use with clinical interview data (SCORS-CDI; Westen, Barends, Leigh, Mendel, & Silbert, 1990 ). Four SCORS dimensions were evaluated. Data were collected in a psychiatric sample (N = 74). Results show that although interrater reliability was good for all dimensions, internal consistency was low, especially for the affective dimensions. Structural equation modeling, in which a model with 2 factors (i.e., SCORS-TAT and SCORS-CDI) and 4 dimensions each was tested, indicated low convergence between corresponding dimensions of SCORS-TAT and SCORS-CDI. Correlational analyses suggested that this was due to a strong method factor. Regression analyses, however, revealed that the presence of a personality disorder operated as a moderator for convergence between corresponding cognitive-structural dimensions.

Defense and object relational maturity on Thematic Apperception Test scales indicate levels of personality organization.

Psychoanalytic theories describe defense mechanisms and object relations as psychological structures that have functions vital to personality regulation. In theory, these structures develop in stages and emerge as a coordinated, stable system in early adulthood. However, different levels of maturity of systemic function predominate in various individuals so that people exhibit levels of personality organization (LPO; Kernberg, 1975) differing in degree of maturity. Moreover, the various LPO of adults parallel various developmental stages of maturity of these structures in childhood and predispose to varying psychopathologies. We call this the parallelism hypothesis: Adult LPO parallels the stages of childhood development of these structures. In 2 studies (Study 1, students, n = 301; Study 2, diagnosed and presumed normal people, n = 155), we compared indicators of LPO with relative maturity of defenses and object relations using Thematic Apperception Test (Murray, 1943) scales (Cramer, 1991; Westen, Lohr, Silk, Kerber, & Goodrich, 1989). We compared scores to other indicators of participants' LPO. The parallelism hypothesis was largely supported in both studies.

Are there racial differences in the experience of harmful or traumatic events within psychiatric settings?

The current study examined racial differences in the reported frequency and distress associated with potentially harmful or traumatic experiences occurring within psychiatric settings. One hundred and forty-two (109 African-American; 32 Caucasian) randomly selected adult consumers recruited from a community psychosocial day program completed a battery of self-report measures to assess experiences in the psychiatric setting, lifetime trauma exposure, PTSD severity, and were the subject of a chart review. A subset of participants (20%) also completed a qualitative interview exploring their perceptions of events occurring in psychiatric settings. Few racial differences were noted in the reported frequency or distress associated with particular events in the psychiatric setting. However, we found differential patterns of association between adverse psychiatric events and lifetime trauma history, and racial differences in diagnosis and medications prescribed by the mental health center. These racial differences merit further attention to better understand their meaning and to improve mental health services provided to both African-Americans and Caucasian public-sector psychiatric patients.

Assessment of implicit motives with a research version of the TAT: picture profiles, gender differences, and relations to other personality measures.

Four hundred twenty-eight participants wrote imaginative stories in response to 6 picture cues of a research version of the Thematic Apperception Test (TAT; Morgan & Murray, 1935). Story protocols were coded for n (need) Power, n Achievement, and n Affiliation using Winter's (1991) integrated scoring system that provided detailed information about the motive profiles of individual picture cues. In general, picture cues differed strongly from each other with regard to how many scorable instances of power, achievement, or affiliation imagery they elicited. The n Affiliation, but not n Power, n Achievement, or activity inhibition--a measure of impulse control--was found to be higher in (a) women than in men and (b) individuals tested in a group than in individuals tested individually. TAT motive measures showed no significant overlap with questionnaire measures of motivational orientation (German Personality Research Form; Stumpf, Angleitner, Wieck, Jackson, & Beloch-Till, 1985) or traits (German NEO-Five-Factor Inventory; Borkenau & Ostendorf, 1993).

A compreensäo psicológica de ex-casais periciados em processos de disputa de guarda e regulamentaçäo de visitas / The psychological understanding of ex-couples investigated in lawsuits disputing custody and visiting schedules

A perícia psicológica nas Varas da Família é um assunto pouco conhecido. Os estudos existentes sobre o tema dizem respeito à problemática afetiva dos periciados, mas säo generalizaçöes tal como säo separaçöes mal sucedidas, ou entäo, os periciados buscam a Justiça apenas para continuarem unidos através de brigas, generalizaçöes que dados empíricos refutam com certa facilidade. Em nosso estudo, além de consideraçöes gerais sobre a prática do trabalho de perito e a especificidade do psicodiagnóstico nesta prática, realizamos três estudos de caso, que mostramos em detalhe, escolhidos aleatoriamente. Para a análise dos casos utilizamo-nos do referencial teórico psicanalítico, bem como das técnicas projetivas de Rorschach - conforme o método de Chabert - e do T.A.T. - conforme o método de Shentoub. Um dos resultados deste estudo procura evidenciar que os distúrbios próprios à paternidade säo no mínimo täo importantes quanto aqueles únicos levantados pelos estudos existentes, ou seja, distúrbios entre os membros do ex-casal que disputam a guarda e regulamentaçäo de visitas. A partir de nossas descobertas elaboramos sugestöes em relaçäo ao trabalho do psicólogo nas Varas da Família, que atendam à demanda do maior número de problemáticas encontradas pelas pessoas que buscam a Justiça

Interest and limitations of projective techniques in the assessment of personality disorders.

Assessing personality disorders (PD) remains a difficult task because of persistent problems linked to concurrent validity of existing instruments, which are all structured interviews or self-report inventories. It has been advocated that indirect methods, projective techniques in particular, can strengthen PD assessment methods. The thematic apperception test (TAT) may be a significant adjuvant method of PD assessment.

Use of the TAT in the assessment of DSM-IV cluster B personality disorders.

The Social Cognition and Object Relations Scale (SCORS), developed by Western, Lohr, Silk, Kerber, and Goodrich (1985), is a diagnostic instrument used to assess an array of psychological functioning by using clinical narratives such as the Thematic Apperception Test (TAT; Murray, 1943) stories. This study investigated the utility of the SCORS to differentiate between Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) antisocial personality disorder (ANPD), borderline personality disorder (BPD), narcissistic personality disorder (NPD), and Cluster C personality disorder (CPD). A sample of 58 patients was separated into four groups: ANPD (n = 9), BPD (n = 21; 18 with a primary BPD diagnosis and 3 with prominent borderline traits who met 4 of the 5 DSM-IV criteria necessary for a BPD diagnosis), NPD (n = 16; 8 with a primary NPD diagnosis and 8 with prominent narcissistic traits who met 4 of the 5 DSM-IV criteria necessary for a NPD diagnosis), and CPD (n = 12). These groups were then compared on the 8 SCORS variables by using 5 TAT cards (1, 2, 3BM, 4, and 13MF). Spearman-Brown correction for 2-way mixed effects model of reliability for the 8 SCORS variables ranged from .70 to .95. The results of categorical and dimensional analyses indicate that (a) SCORS variables can be used to differentiate ANPD, BPD, and NPD; (b) the BPD group scored significantly lower (greater maladjustment) than did the CPD group on certain variables; (c) the BPD group scored significantly lower (greater maladjustment) than did the NPD group on all 8 SCORS variables; (d) the ANPD group scored significantly lower than did the NPD group on certain variables; (e) certain variables were found to be empirically related to the total number of DSM-IV ANPD, BPD, and NPD criteria; and (f) certain variables were found to be empirically related to Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Personality disorder scales. The results of this study are discussed in terms of clinical utility, conceptual, and theoretical implications.

TAT results in a longitudinal study of bereaved college students.

The authors analyzed projective data obtained from 141 college students who wrote stories on three separate occasions to selected cards from the Thematic Apperception Test (TAT). The students included 46 members of support groups for bereaved college students, 34 members of a bereavement control group, and 61 nonbereaved students. The study used a repeated-measures pretest-posttest control group design to gather longitudinal data about the trajectory of bereavement with and without support group intervention. Coders, who reached consistently high interrater reliability, looked for themes of death, grief, coping, and affiliation in the stories. Multivariate analysis of variance (MANOVA) and repeated-measures MANOVA tests were applied to analyze coding results. Overall MANOVA results indicated significant group differences in the responses to the TAT cards. Repeated-measures MANOVA found group differences in use of themes of death and grief and found Group x Time differences in maintaining a sense of self-efficacy while in a crisis. A majority of the stories contained affiliation imagery but without any group differences in the use of such imagery.