Impact of liminality and rituals on professional identity formation in physician training.

PURPOSE: The transition from medical student to practicing physician affects the complex processes of professional identity formation and professionalism, which have a lasting effect on the physician's career development. This study explored two different transitional processes of medical students in Taiwan, the associated rituals during this transitional period (the 'liminal phase') and their effect on the formation of professional identity. METHOD: Using snowball sampling, we recruited 13 medical students from two training systems: six from the traditional postgraduate year programme and seven from the accelerated postgraduate year (A-PGY) programme. Semi-structured interviews were thematically analysed to identify significant themes that encapsulated trainees' experiences. A consistent and mutually confirmed discussion ensured the identification of robust recurring themes. RESULTS: A comparative analysis of the two training modalities provided critical insights into the relative impact of the training dynamics. The A-PGY cohort, subjected to an altered 'incorporation' ritual, encountered an influx of unexpected symbolic social power, complicating their transformation within the liminal phase. Without a defined internship like in the PGY system, A-PGY trainees exhibited confusion and inconsistencies in professional identity formation marked by conflicting internal and external perceptions. This ambiguity affected their clinical training, social integration and overall development of professionalism. The absence of a structured, sequential liminal phase increased conflict and diminished motivation, culminating in an incomplete self-crafting journey for A-PGY trainees. CONCLUSIONS: This study highlights the impact of the well-sequenced implementation of rituals in liminality on professional identity formation. A good transition training programme for medical students should compass sequential rituals in the liminal phase, including clear starting and ending points, supervision by seniors, guided reflection and plenty of opportunities for observation and imitation in context. Optimal training and pivotal elements in a medical training system warrant delicate design and further research when developing and changing the structure of the training programme.

Gender differences in the intention to withhold life-sustaining treatments involving severe dementia for self and on behalf of parent or spouse.

BACKGROUND: Few studies have explored gender differences in the attitudes toward advanced care planning and the intention to withhold life-sustaining treatments (LSTs) involving severe dementia in Asian countries. We examined gender differences in the attitude toward the Patient Autonomy Act (PAA) in Taiwan and how the gender differences in these attitudes affect the intention to withhold LSTs for severe dementia. We also investigated self-other differences in the intention to withhold LSTs between genders. METHODS: Between March and October 2019, a structured questionnaire was distributed to hospitalized patients' family members through face-to-face contact in an academic medical center. Exploratory factor analysis and independent and paired-sample t-tests were used to describe gender differences. Mediation analyses controlled for age, marital status, and education level were conducted to examine whether the attitude toward the PAA mediates the gender effect on the intention to withhold LSTs for severe dementia. RESULTS: Eighty respondents filled out the questionnaire. Exploratory factor analysis of the attitude toward the PAA revealed three key domains: regarding the PAA as (1) promoting a sense of abandonment, (2) supporting patient autonomy, and (3) contributing to the collective good. Relative to the men, the women had lower average scores for promoting a sense of abandonment (7.48 vs. 8.94, p = 0.030), higher scores for supporting patient autonomy (8.74 vs. 7.94, p = 0.006), and higher scores for contributing to the collective good (8.64 vs. 7.47, p = 0.001). Compared with the women, the men were less likely to withhold LSTs for severe dementia (15.84 vs. 18.88, p = 0.01). Mediation analysis revealed that the attitude toward the PAA fully mediated the gender differences in the intention to withhold LSTs for severe dementia. Both men and women were more likely to withhold LSTs for themselves than for their parents. Compared with the women, the men were more likely to withhold resuscitation for themselves than for their parents (p = 0.05). Women were more likely to agree to enteral tube feeding and a tracheotomy for their husbands than for themselves; men made consistent decisions for themselves and their wives in those LST scenarios. CONCLUSION: Gender influences the attitude toward advanced care planning and consequently affects the intention to withhold LSTs, indicating that there may be a difference in how men and women perceive EOL decision-making for severe dementia in Taiwan. Further studies are warranted.

Medical students' affective reactions to workplace experiences: qualitative investigation in a Chinese cultural context.

BACKGROUND: Compassion fatigue, unprofessional behavior, and burnout are prompting educators to examine medical students' affective reactions to workplace experiences. Attributes of both students and learning environments are influenced by their socio-cultural backgrounds. To prevent 'educational cultural hegemony', opinion leaders have advocated research in under-represented cultural contexts, of which Asia is a prime example. This study aimed to broaden the discourse of medical education by answering the question: how do students react affectively to workplace experiences in a Chinese cultural context? METHODS: In 2014, the authors recruited five female and seven male Taiwanese clerkship students to make 1-2 audio-diary recordings per week for 12 weeks describing affective experiences, to which they had consciously reacted. The authors analyzed transcripts of these recordings thematically in the original Mandarin and prepared a thick description of their findings, including illustrative extracts. An English-speaking education researcher helped them translate this into English, constantly comparing the interpretation with the original, untranslated data. RESULTS: (Mis) matches between their visions of future professional life and clerkship experiences influenced participants' affective reactions, thoughts, and behaviors. Participants managed these reactions by drawing on a range of personal and social resources, which influenced the valence, strength, and nature of their reactions. This complex set of interrelationships was influenced by culturally determined values and norms, of which this report provides a thick description. CONCLUSION: To avoid educational cultural hegemony, educators need to understand professional behavior in terms of complex interactions between culturally-specific attributes of individual students and learning environments. TRIAL REGISTRATION: The ethics committee of the National Taiwan University (NTU) Hospital gave research ethics approval ( 20130864RINB ).

Outcomes of overseas kidney transplantation in chronic haemodialysis patients in Taiwan.

AIM: Overseas kidney transplantation has often been reported to have unsatisfactory outcomes. This study aims to compare post-transplantation outcomes between overseas and domestic kidney transplant (KT) recipients in Taiwan. METHODS: The Taiwanese National Health Insurance Research Database was used to identify 310 domestic and 643 overseas KT recipients, who survived for longer than 1 month after the transplantation, in a cohort of 45,453 chronic haemodialysis patients in 1997-2002. Cox proportional hazards models were used to assess risks of mortality and graft failure. RESULTS: The 1, 3 and 5 year survival rates for domestic KT recipients were 96.5%, 93.3% and 91.6%, respectively, while those for overseas KT recipients were 94.9%, 87.9% and 77.1%, respectively (P = 0.015). For the overseas group, those who received a KT before 2001 had significantly higher hazard ratios of mortality and graft failure (2.85 and 1.71, respectively). However, for those receiving a KT in 2001-2002, no significant outcome difference could be found between overseas and domestic recipients. CONCLUSION: The risk disparity between overseas and domestic KT recipients is mainly attributable to when the transplantation was performed. In attempting to dissuade potential recipients from organ trafficking, merely emphasizing the previously acknowledged poor outcomes no longer suffices as a valid reason.

Whole-genome association studies for multigenic diseases: ethical dilemmas arising from commercialization--the case of genetic testing for autism.

This paper examines some ethical issues arising from whole-genome association studies for multigenic diseases, focusing on the case of autism. Events occurring following the announcement of a genetic test for autism in France (2005-2009) are described to exemplify the ethical controversies that can arise when genetic testing for autism is applied prematurely and inappropriately promoted by biotech companies. The authors argue that genetic tests assessing one or a few genes involved in highly multigenic disorders can only be useful if: (1) the genetic linkage found in the scientific study must be statistically convincing, reproducible and also applicable to the population to which the individual considered belongs (scientific validity); (2) the relative risk conferred by the 'high-risk' allele should be high enough to be significant to the patient (significant impact); (3) use of the test should lead to some improvement of outcome for the patient, resulting from adapted treatment if available, or at least from adjustment of lifestyle (or life goals) prompted by the new knowledge generated (clinical utility). Decisions concerning genetic testing for autism involve scientific judgement, value judgement and good knowledge of a constantly evolving therapeutic environment. The implementation of genetic tests for highly multigenic diseases thus requires strong mechanisms to ensure that they are used in a fashion that can benefit patients, and these mechanisms must be able to cope with rapid progress in scientific knowledge and therapeutic intervention.

Impact of major illnesses and geographic regions on do-not-resuscitate rate and its potential cost savings in Taiwan.

BACKGROUND/PURPOSE: Do-not-resuscitate (DNR) is a legal order that demonstrates a patient's will to avoid further suffering from advanced treatment at the end of life. The concept of palliative care is increasingly accepted, but the impacts of different major illnesses, geographic regions, and health expenses on DNR rates remain unclear. METHODS: This study utilized the two-million National Health Insurance (NHI) Research Database to examine the percentage of DNR rates among all deaths in hospitals from 2001 to 2011. DNR in the study was defined as no resuscitation before death in hospitals. Death records were extracted from the database and correlated with healthcare information. Descriptive statistics were compiled to examine the relationships between DNR rates and variables including major illnesses, geographic regions, and NHI spending. RESULTS: A total of 126,390 death records were extracted from the database for analysis. Among cancer-related deaths, pancreatic cancer patients had the highest DNR rate (86.99%) and esophageal cancer patients had the lowest DNR rate (71.62%). The higher DNR rate among cancer-only patients (79.53%) decreased with concomitant dialysis (66.07%) or ventilator use (57.85%). The lower DNR rates in patients with either chronic dialysis (51.27%) or ventilator use (59.10%) increased when patients experienced these two conditions concomitantly (61.31%). Although DNR rates have consistently increased over time across all regions of Taiwan, a persistent disparity was noted between the East and the South (76.89% vs. 70.78% in 2011, p < 0.01). After adjusting for potential confounders, DNR patients had significantly lower NHI spending one year prior to death ($67,553), compared with non-DNR patients. CONCLUSION: Our study found that DNR rates varied across cancer types and decreased in cancer patients with concomitant chronic dialysis or ventilator use. Disparities in DNR rates were evident across geographic regions in Taiwan. A wider adoption of the DNR policy may achieve substantial savings in health expenses and improve patients' quality of life.

Gynecologists' perception of the patient-physician relationship in pelvic examinations in Taiwan.

OBJECTIVE: To explore the gynecologists' physical contact and their interaction with patients, as well as the patient-physicians relationship during the pelvic examination (PE). STUDY DESIGN: This qualitative study uses face-to-face, in-depth interviews with 20 gynecologists from three hospitals in central Taiwan. RESULTS: The results revealed two main categories: adopting non-gendered and desexualised strategies and acknowledging a patient's situation. The majority of gynecologists adopted strategies to reduce their embarrassment during a PE, such as the use of a PE curtain, having a nurse in attendance, the tendency to depend on an ultrasound scan and the use of minimal verbal communication. CONCLUSION: Within the social context in Taiwan, male gynecologists tend to adopt a non-gendered and desexualised attitude to lessen the embarrassment and to protect them from accusations of sexual misconduct by patients during the PE. Acknowledging a patient's situation can benefit the gynecologists and allowed them to conduct the PE more easily. The results could possibly provide the medical student with an awareness and reflection of how social interaction plays a role for the gynecologists and their patients during a PE.

The outcomes and controversies of transplant tourism-Lessons of an 11-year retrospective cohort study from Taiwan.

BACKGROUND: Transplant tourism has increased rapidly in the past two decades, accounting for about 10% of world organ transplants. However it is ethically controversial and discouraged by professional guidelines. We conducted this study to investigate the outcomes and trends of overseas kidney and liver transplantation in Taiwan to provide a sound basis for ethical reflection. METHODS AND FINDINGS: The Taiwanese National Health Insurance Research Database was used to identify 2381 domestic and 2518 overseas kidney transplant (KT) recipients from 1998 to 2009 and 1758 domestic and 540 overseas liver transplantation (LT) recipients from 1999 to 2009. Cox proportional hazards models were used to assess the risks of mortality and graft failure. The numbers of overseas transplantation increased after 2000, reached a peak in 2005 and decreased after 2007. Compared to their domestic counterparts, the overseas KT recipients were older, male predominant, with shorter pre-op dialysis period and more comorbidities. Similarly, the overseas LT recipients were older, male predominant and had more hepatocellular carcinoma cases. The 1-, 5-, and 10-year patient survival rates were 96.9%, 91.7% and 83.0% respectively for domestic KT and 95.8%, 87.8% and 73.1% for overseas KT (p<0.001). The 1-, 5-, and 10-year patient survival rates were 89.2%, 79.5%, 75.2% for domestic LT and 79.8%, 54.7%, 49.9% for overseas LT (p<0.001). CONCLUSION: The poorer outcomes of the overseas groups may be due to more older patients, more comorbidities (KT), or more hepatocellular carcinoma recurrences (LT). After domestic reform and international ethical challenges, the numbers of organ tourism decreased but the practice still persisted surreptitiously. Compulsory registration policies for overseas transplantation with international conventions to sanction organ trafficking and transplant tourism should be considered to stop these controversial practices.

ELSI practices in genomic research in East Asia: implications for research collaboration and public participation.

Common infrastructures and platforms are required for international collaborations in large-scale human genomic research and policy development, such as the Global Alliance for Genomics and Health and the 'ELSI 2.0' initiative. Such initiatives may require international harmonization of ethical and regulatory requirements. To enable this, however, a greater understanding of issues and practices that relate to the ethical, legal and social implications (ELSI) of genomic research will be needed for the different countries and global regions involved in such research. Here, we review the ELSI practices and regulations for genomic research in six East Asian countries (China, Indonesia, Japan, Singapore, South Korea and Taiwan), highlighting the main similarities and differences between these countries, and more generally, in relation to Western countries. While there are significant differences in ELSI practices among these East Asian countries, there is a consistent emphasis on advancing genomic science and technology. In addition, considerable emphasis is placed on informed consent for participation in research, whether through the contribution of tissue samples or personal information. However, a higher level of engagement with interested stakeholders and the public will be needed in some countries.

An oath for bioscientists.

In this paper, by examining the idea of a 'Hippocratic Oath for scientists', promoted by Sir Joseph Rotblat, oaths for medical professionals and scientists and the definitions and relationships of different moral norms such as oaths, codes and guidelines, we propose an oath for bioscientists with justifications based on professional and organizational ethics.