Ways of Being in Generalist Practice: Using Five "T" Habits of Mind to Guide Ethical Behavior.

The practice of generalist medicine differs from the practice of other clinical disciplines. We postulate that the application of ethics in generalist practice similarly differs from its application in other healthcare settings. In contrast to the problem-focused practice of ethics in other medical specialties, the practice of ethics in generalist medicine blends habits of mind with behaviors applied routinely over time-an ethical way of being. Using a graphic summary and tabular matrix, we present five "T" habits of mind (time, talk, tact, touch, and trust), associate them with applicable practice characteristics, and link them to observable clinician behaviors to demonstrate how the application of ethics in generalist practice is a day-to-day endeavor and not simply a means to resolve episodic conflicts. We textually review key aspects of the matrix and present two case studies that illustrate how such habits of mind and practice behaviors inform the ethical way of being we espouse. We invite generalist practitioners to incorporate the five "T" habits and associated behaviors into their daily care of patients, and we encourage clinical ethicists and other clinical faculty members to consider using them as a model for ethics education with medical students and resident physicians.

Toward interprofessional service-learning and social accountability in health: One South African University's process-oriented-participatory journey.

The Nelson Mandela University in Port Elizabeth, South Africa, seeks to transform its health professions curricula in order to achieve equity in health outcomes. Integral to this are interprofessional education service-learning initiatives attendant to socially accountable objectives. We describe one such initiative, the Zanempilo Mobile Health Education Platform (MHEP), which engages interprofessional healthcare students and faculty members in delivering health services to underserved communities. The Zanempilo MHEP consists of a converted 13-ton truck as a mobile clinic from where student-run services are provided. We illustrate the intentional process by which we, an interprofessional health science working group, created socially accountable learning goals appropriate to the above platform. We developed, employed, and refined a process-oriented-participatory approach rooted in theories of social constructivism and social network development that included the following phases: orientation, analysis, synthesis, production, and dissemination. Out of this approach emerged several socially accountable learning goals for students and faculty members working on the Zanempilo MHEP. These goals incorporated five educational domains, namely knowledge, attitudes, skills, intentions, and relationships. We anticipate using these goals to identify future curricular objectives and competencies.

Time for action: key considerations for implementing social accountability in the education of health professionals.

Within health professional education around the world, there exists a growing awareness of the professional duty to be socially responsible, being attentive to the needs of all members of communities, regions, and nations, especially those who disproportionately suffer from the adverse influence of social determinants. However, much work still remains to progress beyond such good intentions. Moving from contemplation to action means embracing social accountability as a key guiding principle for change. Social accountability means that health institutions attend to improving the performance of individual practitioners and health systems by directing educational and practice interventions to promote the health of all the public and assessing the systemic effects of these interventions. In this Reflection, the authors (1) review the reasons why health professional schools and their governing bodies should codify, in both curricular and accreditation standards, norms of excellence in social accountability, (2) present four considerations crucial to successfully implementing this codification, and (3) discuss the challenges such changes might entail. The authors conclude by noting that in adopting socially accountable criteria, schools will need to expand their philosophical scope to recognize social accountability as a vitally important part of their institutional professional identity.

Looking Within: Intentions of Practice for Person-Centered Care.

In order to integrate the biological, psychological, social, and existential dimensions of care into my day-to-day clinical encounters with patients, I have worked to cultivate several intentions of practice. These intentions of practice-habits of mind that nurture my resolve to attend to patients as complex human beings- help me navigate my interactions with patients and families in ways that are simultaneously efficacious and therapeutic. When routinely recalled and adeptly implemented, they are what distinguish me as a competent and capable practitioner of person-centered care, when I am at my best, from when I am not. I present them here in hopes that others may find them useful as they progress down their ongoing paths as healing physicians.

Healing.

My personal ethos of healing is an expression of the belief that I can and do act to heal patients while I attend to the traditional goals of medicine. The 7 supporting principles that inform my ethos are dignity, authenticity, integrity, transparency, solidarity, generosity, and resiliency. I invite others, including medical students, residents, and practicing physicians, to reflect and discover their own ethos of healing and the principles that guide their professional growth. A short digital documentary accompanies this essay for use as a reflective prompt to encourage personal and professional development.

Building Power Between Polarities: On the Space-in-Between.

In this article, I introduce the concept of the space-in-between. This space-in-between is born of the realization that, between the expression of any two polarities (across dimensions such as emotion, thought, geography, and ideology), there exists a philosophical construct useful for framing thinking about practice, research, and managerial relationships in the health professions. Out of this construct emerge practical considerations useful for structuring the conduct of meaningful interpersonal and intercultural interactions. I describe how the idea of a space-in-between developed out of my medical practice, grew as a result of my experiences in international environments. and has found fulfillment in my ongoing work. I explore the application of a space-in-between in public health, medical anthropology, medical ethics, and global health. I review how, as a result of incorporating this space in their daily work, clinicians, educators, researchers, and managers can grow as leaders by sharing the presence that arises from the space-in-between them and the people in the communities they serve.

ABCDE in Clinical Encounters: Presentations of Self in Doctor-Patient Communication.

Professional discussions about communication in medical settings often ignore the various personal identities that doctors and patients bring to their clinical encounters. From my 26 years as a family physician, and informed by literature from other professional disciplines, I propose an alternate understanding: to think of doctors and patients as a collection of individual identities, each formed by a discrete presentation of self. I describe how at least 5 important presentations of self arise in clinical encounters, including those relating to meaning, community, agency, anxiety, and organism. I frame these presentations of self with the mnemonic ABCDE, briefly review key dimensions of each, and suggest how physicians can reflect on these dimensions in order to find equilibrium in their interactions with patients. Lastly, I submit that finding this balance can reduce relational challenges with patients and enhance the therapeutic effectiveness of doctor-patient communication.

Beyond ethical and curricular guidelines in global health: attitudinal development on international service-learning trips.

BACKGROUND: Health professionals from high-income countries are increasingly becoming involved in international service-learning trips in low and low/middle-income countries. While much has been written about the ethics and curricular guidelines related to such endeavors, scant attention has been paid to the attitudes with which trainees and clinicians enter into or return from them. In this essay the authors explore how attitudes contribute to the success or failure of international service-learning trips. DISCUSSION: The authors submit that the attitudes with which visiting health professionals approach international service-learning trips are much more critical to the success of these experiences than their demonstrated knowledge base or specialized skill sets. They list five attitudes that can aid those participating in international service-learning trips. They list five troubling attitudes that, while common, those participating in international service-learning trips can learn to recognize and avoid. They suggest five strategies key to learning respectful attitudes that can foster success in such cross-cultural activities. Lastly, the authors review several concepts related to attitude development in short or long-term global health work. SUMMARY: The attitudes with which visiting health professionals approach international service-learning activities can be important components of the success or failure of the experiences. Through thoughtful consideration of attitudes and approaches, participants on such trips can build a framework for rich and rewarding experiences in global medicine and global health.

Eyes wide open: an essay on developing an engaged awareness in global medicine and public health.

BACKGROUND: There is a growing understanding of the role social determinants such as poverty, gender discrimination, racial prejudice, and economic inequality play on health and illness. While these determinants and effects may be challenging to identify in parts of high-income countries, they are patently obvious in many other areas of the world. How we react to these determinants and effects depends on what historical, cultural, ideological, and psychological characteristics we bring to our encounters with inequity, as well as how our feelings and thoughts inform our values and actions. DISCUSSION: To address these issues, we share a series of questions we have asked ourselves-United States' citizens with experience living and working in Central America-in relation to our encounters with inequity. We offer a conceptual framework for contemplating responses in hopes of promoting among educators and practitioners in medicine and public health an engaged awareness of how our every day work either perpetuates or breaks down barriers of social difference. We review key moments in our own experiences as global health practitioners to provide context for these questions. Introspective reflection can help professionals in global medicine and public health recognize the dynamic roles that they play in the world. Such reflection can bring us closer to appreciating the forces that have worked both for and in opposition to global health, human rights, and well-being. It can help us recognize how place, time, environment, and context form the social determination of health. It is from this holistic perspective of social relations that we can work to effect fair, equitable, and protective environments as they relate to global medicine and public health.

Storylines of family medicine I: framing family medicine - history, values and perspectives.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'I: framing family medicine-history, values, and perspectives', the authors address the following themes: 'Notes on Storylines of Family Medicine', 'Family medicine-the generalist specialty', 'Family medicine's achievements-a glass half full assessment', 'Family medicine's next 50 years-toward filling our glasses', 'Four enduring truths of family medicine', 'Names matter', 'Family medicine at its core' and 'The ecology of medical care.' May readers find much food for thought in these essays.

Storylines of family medicine VIII: clinical approaches.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.

Storylines of family medicine XI: professional identity formation-nurturing one's own story.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XI: professional identity formation-nurturing one's own story', authors address the following themes: 'The social construction of professional identity', 'On becoming a family physician', 'What's on the test?-professionalism for family physicians', 'The ugly doc-ling', 'Teachers-the essence of who we are', 'Family medicine research-it starts in the clinic', 'Socially accountability in medical education', 'Personal philosophy and how to find it' and 'Teaching and learning with Storylines of Family Medicine'. May these essays encourage readers to find their own creative spark in medicine.