'Constrained collaboration': Patient empowerment discourse as resource for countervailing power.

Countervailing powers constrain the authority and autonomy of the medical profession. One countervailing power is patient consumerism, a movement with roots in health social movements. Patient empowerment discourses that emerge from health social movements suggest that active patienthood is a normative good, and that patients should inform themselves, claim their expertise, and participate in their care. Yet, little is known about how patient empowerment is understood by physicians. Drawing on ethnographic fieldwork in an American medical school, this article examines how physicians teach medical students to carry out patient encounters while adhering to American cultural expectations of a collaborative physician-patient relationship. Overt medical paternalism is characterised by professors as 'here's the orders' paternalism, and shown to be counterproductive to 'closing the deal' - achieving patient agreement to a course of treatment. To explain how physicians accomplish their therapeutic goals without violating cultural mandates of patient empowerment I develop the concept of 'constrained collaboration'. This analysis of constrained collaboration contrasts with structural-level narratives of diminishing professional authority and contributes to a theory of the micro-level reproduction of medical authority as a set of interactional practices.

Cultural health capital and patient partner recruitment into healthcare improvement work.

A rising emphasis on patient involvement in clinical research and healthcare improvement has led to the steady incorporation of patients and caregivers into this work. However, interactional factors shaping recruitment processes are not well understood. In this paper, we present a qualitative analysis of interviews with twenty-six patients, family members, engagement staff and healthcare providers who are engaged in healthcare improvement work in the United States. We focus on how stakeholders account for recruitment decisions to participate in healthcare improvement work. We find that expressions of and judgments about patients' and caregivers' cultural health capital shape providers' decisions to extend invitations to participate in healthcare improvement work. These findings extend current conceptualizations of cultural health capital beyond the clinical encounter to reveal factors shaping patient recruitment into healthcare improvement work. In theorizing how cultural health capital shapes action in this new setting, we found that healthcare providers, engagement staff, and patients/caregivers attended to different aspects of cultural health capital when accounting for why they extended or received a recruitment pitch. We further found that participating in healthcare improvement work led to a boost in cultural health capital for patients and caregivers, which they could use to develop transmissible forms of cultural health capital for less centrally involved patients and caregivers. Finally, we describe how participants in healthcare improvement collaboratives account for a lack of diversity among partners. These findings help us hypothesize the consequences of recruitment processes that rely on displays and judgments of cultural health capital and identify possibilities for change. Using the case of healthcare improvement work in Collaborative Learning Health Systems, our findings advance past work on cultural health capital in medical sociology by theorizing the role of cultural health capital in recruitment processes.

Complexity and Challenges of Cross-Cover Care in Graduate Medical Education: A Qualitative Study.

PURPOSE: Cross-cover care (care for hospitalized patients when the primary team is absent) is a common graduate medical education responsibility; however, it may lead to increased preventable adverse events. Despite understanding the difficulties of cross-cover care, medical educators lack comprehensive knowledge of specific challenges that residents face and how they handle these challenges. This study explores the challenges residents experience when providing cross-cover care. METHOD: The authors conducted 60 semistructured, qualitative interviews with 20 internal medicine and surgery residents at a single academic institution between October 2021 and April 2022. Each resident participated in 3 interviews, 2 immediately after a shift. Working inductively, the authors generated codes for important themes. Study design and data collection were guided by interpretive description, a qualitative approach for health care research focused on experiences and perceptions to develop meaningful findings. To illustrate residents' workflow and aid in quality improvement efforts, the authors created a process map. RESULTS: Seventeen cross-cover challenges were organized into 7 interrelated and overlapping themes: lack of baseline knowledge, inadequate or inaccurate information transfer from the primary team, unfamiliarity with cross-cover patients, high task volume leading to increased interruptions, ill-defined roles leading to unmet expectations from others, perceived decreased access to resources, and fatigue. The process map illustrates 4 cross-cover workflow components: information transfer from the primary team to the cross-cover team, direct handling of cross-cover tasks that are assigned by the primary team or that arise during the time of cross-cover, information transfer back to primary team and other care team members, and responsibilities that residents have overnight that are not directly related to cross-cover. CONCLUSIONS: Residents face substantial challenges when providing cross-cover care, which have important implications for patient safety and resident well-being. The medical community should strive to develop educational and structural interventions to improve this process.

Articulating the canon: The sociology of medical education from 1980 to 2000.

An exciting development in the sociology of medical education has been its recent return as a distinct scholarly conversation in medical sociology. During the 1980s and 1990s, the sociology of medical education, an historically prominent subfield in sociology, seemed to disappear from the scholarly conversation despite ongoing development in this area. In this narrative review I describe this "missing period" of sociology of medical education, discussing complementary explanations for why it receded and describing what research activity did take place during those decades. In reviewing this work, I argue that articulating theoretical advances made within sociology of medical education research during these decades allows us to link foundational research from the 1950s and 1960s with the renaissance of this subfield in the early 2000s. Fundamentally, understanding the intellectual history and development of this subfield supports a broader movement to understand the import of studies of medical training for exploring questions of interest in general sociology.

Online student culture as site for negotiating assessment in medical education.

Classic studies of medical education have examined how professional socialization reproduces the prevailing professional culture, as well as how students actively negotiate their place in educational processes. However, sociological research has not re-examined student culture in light of structural transformations in medical education, such as the introduction of new assessment types and their use as modes of commensuration. In this paper, we examine data from two studies of online forums where medical trainees and applicants to medical school discuss their experiences preparing for tests of professional skills, including judgment, empathy, and communication. Examining how medical students talk about these tests on such forums allows us to understand the meaning-making processes at work as students negotiate the commensuration processes such tests enable. We examine how these negotiations take place in online forums, where participants confront common challenges, form common perspectives, and share common solutions, all hallmarks of student culture. Through qualitative analysis, we find that online communities are spaces where students grapple with these new forms of commensuration, interrogate the standards and quantifications that underlie them, and collectively negotiate how to approach these assessments. Using the case of online forum communities, our findings advance past work on student culture in medical sociology by theorizing student culture as an extra-organizational phenomenon that spans multiple career stages. In so doing, we highlight the importance of online forum data for studying social processes.

Collaborative conversations during the time of COVID-19: Building a "meta"-learning community.

PROBLEM: COVID-19 created new research, clinical, educational, and personal challenges, while simultaneously separating work teams who were under work-from-home restrictions. Addressing these challenges required new forms of collaborative groups. APPROACH: To support the department community and the rapid sharing of new research, educational, clinical, and personal efforts, a Core Team from the Department of Learning Health Sciences at the University of Michigan developed a meeting series called the COVID Conversations. This Experience Report shares the organizational structure of the COVID Conversations, proposes a comparison to traditional Learning Communities, and reports the results of a questionnaire that gathered details about department members' COVID-related activities. OUTCOMES: We identify and describe salient similarities and differences between the COVID Conversations and the characteristics of Learning Communities. We also developed and piloted a taxonomy for characterizing LHS research projects that may be further developed for use in Learning Community planning, in conjunction with other maturity grids and ontologies. We propose the term "Meta-Learning Community" to describe the structure and function of the COVID Conversations. NEXT STEPS: In academic medicine, remote work, telemedicine, and virtual learning may be here to stay. The COVID Conversations constitute a distinct and innovative form of collaborative work in which separate teams addressing distinct goals, yet sharing a common passion to tackle the issues brought by the pandemic, are able to share experiences and learn from one other. The challenges of COVID-19 have made evident the need for multiple forms of organizing teamwork, and our study contributes the notion of a "Meta"-Learning Community as a new form of collaborative work.

Toward an ontology of collaborative learning healthcare systems.

Objective: To establish a basis for a domain ontology - a formal, explicit specification of a shared conceptualization - of collaborative learning healthcare systems (CLHSs) in order to facilitate measurement, explanation, and improvement. Methods: We adapted the "Methontology" approach to begin building an ontology of CLHSs. We specified the purpose of an ontology, acquired domain knowledge via literature review, conceptualized a common framework of CLHSs using a grounded approach, refined these concepts based on expert panel input, and illustrated concept application via four cases. Results: The set of concepts identified as important to include in an ontology includes goals, values, structure, actors, environment, and products. To establish this set of concepts, we gathered input from content experts in two ways. First, expert panel methods were used to elicit feedback on these concepts and to test the elicitation of terms for the vocabulary of the Values concept. Second, from these discussions we developed a mapping exercise to test the intuitiveness of the concepts, requesting that network leaders from four CLHSs complete a mapping exercise to associate characteristics of their networks with the high-level concepts, building the vocabulary for each concept in a grounded fashion. We also solicited feedback from these participants on the experience of completing the mapping exercise, finding that the exercise is acceptable and could aid in CLHS development and collaboration. Respondents identified opportunities to improve the operational definitions of each concept to ensure that corresponding vocabularies are distinct and non-overlapping. Discussion: Our results provide a foundation for developing a formal, explicit shared conceptualization of CLHSs. Once developed, such a tool can be useful for measurement, explanation, and improvement. Further work, including alignment to a top-level ontology, expanding the vocabulary, and defining relations between vocabulary is required to formally build out an ontology for these uses.

Facilitator Reflections on Shared Expertise and Adaptive Leadership in ECHO Autism: Center Engagement.

INTRODUCTION: Project Extension for Community Healthcare Outcomes (ECHO) is used to increase provider capacity in a wide range of health care specialties. ECHO Autism: Center Engagement is a program that promotes improvement in autism care by improving the management of autism care centers. The program's focus brought experienced clinicians together as both facilitators and participants in an ECHO series. ECHO Autism: Center Engagement facilitators devised a reflective writing exercise to prospectively study their experience leading this new curriculum. METHODS: Drawing on a qualitative thematic analysis of longitudinal reflective writing exercises from seven "Hub Team" facilitators, we describe how ECHO leaders cultivate a learning environment that emphasizes shared learning and acknowledges the expertise of ECHO participants. RESULTS: The analysis generated three main themes: (1) Hub Team facilitators valued reciprocal exchange with Spoke sites, a theme we name "shared learning," (2) Hub Team facilitators demonstrated high levels of awareness about their facilitation styles, and (3) Hub Team facilitators cultivated an interactional style they described as "all teach, all learn." DISCUSSION: Examining the experiences of ECHO facilitators produces qualitative accounts of continuing professional development that may not be captured in other program evaluation approaches. In the case of ECHO Autism: Center Engagement, facilitators cultivated an environment of shared learning, which acknowledged the expertise of both facilitators and participants. These findings are pertinent for scholars of continuing education in health professions who lead educational programs where participants and facilitators have high levels of overlap in their areas of expertise and years of experience.

Culture as infrastructure in learning health systems.

Building Learning Health Systems requires the combination of information, regulatory, and cultural infrastructures that create communities focused on changing health outcomes through the application of quality improvement methodology, focused data collection, closed feedback loops, and community-participatory techniques. Accomplishing the vision of the Learning Health System relies on building robust infrastructures, and teaching a wide variety of stakeholders to participate in these novel socio-technical systems. In this commentary, I draw on empirical examples from fieldwork with Learning Networks to describe how social scientists view culture and what this concept might hold for learning health sciences.

Putting the network to work: Learning networks in rapid response situations.

INTRODUCTION: The rapid response to COVID-19 has necessitated infrastructural development and reorientation in order to safely meet patient care needs. METHODS: A qualitative case study was constructed within a larger ethnographic field study. Document collection and fieldnotes and recordings from nonparticipant observation of network activities were compiled and chronologically ordered to chart the network's response to changes in epilepsy care resulting from COVID-19 and the rapid transition to telemedicine. RESULTS: The network's response to COVID-19 was characterized by a predisposition to action, the role of sharing as both a group practice and shared value, and the identification of improvement science as the primary contribution of the group within the larger epilepsy community's response to COVID-19. The findings are interpreted as an example of how group culture can shape action via a transparent and mundane shared infrastructure. CONCLUSIONS: The case of one multi-stakeholder epilepsy Learning Network provides an example of the use of infrastructure that is shaped by the group's culture. These findings contribute to the development of a social theory of infrastructure within Learning Health Systems.

Sensing defects: Collaborative seeing in engineering work.

This paper explores how professional engineers recognize and make sense of product defects in their everyday work. Such activities form a crucial, if often overlooked, part of professional engineering practice. By detecting, recognizing and repairing defects, engineers contribute to the creation of value and the optimization of production processes. Focusing on early-career engineers in an advanced steel mill in the United States, we demonstrate how learning specific ways of seeing and attending to defects take shape around the increasing automation of certain aspects of engineering work. Practices of sensing defects are embodied, necessitating disciplined eyes, ears, and hands, but they are also distributed across human and non-human actors. We argue that such an approach to technical work provides texture to the stark opposition between human and machine work that has emerged in debates around automation. Our approach to sensing defects suggests that such an opposition, with its focus on job loss or retention, misses the more nuanced ways in which humans and machines are conjoined in perceptual tasks. The effects of automation should be understood through such shifting configurations and the ways that they variously incorporate the perceptual practices of humans and machines.

Learning and Collaboration during Crisis: A Novel University-Community Partnership to Manufacture Medical Personal Protective Equipment.

Research on crisis management focuses on pre-planning for disasters in order to understand potential barriers. However, one significant barrier to crisis response is that organizations may come together in unplanned configurations during crisis response. This means that significant opportunities exist for understanding the process by which individuals learn, collaborate, and create new systems during crises. In this case report, we present the case of face shield production by a university, academic medical center, and community partners during the supply chain collapse of the early COVID-19 pandemic with the aim of identifying the relationships that formed during the COVID-19 response, so that this case of relationship formation and participant experiences might inform similar disaster response challenges in the future. Thirteen participants responded to an in-depth questionnaire designed to simulate an asynchronous in-depth interview. Respondents reported on the activities of 80 individuals from 38 units/organizations, providing insight into communication challenges and resolutions. Responses were analyzed using thematic analysis, highlighting roles and relationships among participants. The findings grant insight into the experience of learning from crisis response efforts, responding to recent calls for social scientific work on COVID-19 responses.

The Resurgence of Medical Education in Sociology: A Return to Our Roots and an Agenda for the Future.

From 1940 to 1980, studies of medical education were foundational to sociology, but attention shifted away from medical training in the late 1980s. Recently, there has been a marked return to this once pivotal topic, reflecting new questions and stakes. This article traces this resurgence by reviewing recent substantive research trends and setting the agenda for future research. We summarize four current research foci that reflect and critically map onto earlier projects in this subfield while driving theoretical development elsewhere in the larger discipline: (1) professional socialization, (2) knowledge regimes, (3) stratification within the profession, and (4) sociology of the field of medical education. We then offer six potential future directions where more research is needed: (1) inequalities in medical education, (2) socialization across the life course and new institutional forms of gatekeeping, (3) provider well-being, (4) globalization, (5) medical education as knowledge-based work, and (6) effects of the COVID-19 pandemic.

Clinical empathy as emotional labor in medical work.

The ongoing social transformation of the American healthcare system brings both structural and interpersonal changes to the delivery of healthcare. Some of these changes have been motivated by patients, who increasingly desire emotionally warm interactions with physicians. This is a departure from the detached concern that characterized physician-patient interactions in the mid-twentieth century. Concurrently, medical training continually adapts to trends in medical practice so that future physicians are prepared to enter practice. In this paper, we examine the rise of clinical skills training courses and assessments in medical school, highlighting the changing role of emotion in training about communication in the doctor - patient relationship. Drawing on an interpretive analysis of interviews with and ethnographic observations of medical students and residents from two United States medical schools, we elaborate the concept of clinical empathy to describe the character of emotional engagement in the contemporary clinical encounter. In the analysis we show how standards of emotional conduct are taught in medical school, how clinical empathy is operationalized in the patient encounter, and how clinical empathy may be used instrumentally to smooth the physician's work. Finally, we position the consistent performance of clinical empathy as a form of emotional labor, expanding the reach of studies of emotional labor in professions.