What makes a 'good doctor'? A critical discourse analysis of perspectives from medical students with lived experience as patients.

What constitutes a 'good doctor' varies widely across groups and contexts. While patients prioritise communication and empathy, physicians emphasise medical expertise, and medical students describe a combination of the two as professional ideals. We explored the conceptions of the 'good doctor' held by medical learners with chronic illnesses or disabilities who self-identify as patients to understand how their learning as both patients and future physicians aligns with existing medical school curricula. We conducted 10 semistructured interviews with medical students with self-reported chronic illness or disability and who self-identified as patients. We used critical discourse analysis to code for dimensions of the 'good doctor'. In turn, using concepts of Bakhtinian intersubjectivity and the hidden curriculum we explored how these discourses related to student experiences with formal and informal curricular content.According to participants, dimensions of the 'good doctor' included empathy, communication, attention to illness impact and boundary-setting to separate self from patients. Students reported that formal teaching on empathy and illness impact were present in the formal curriculum, however ultimately devalued through day-to-day interactions with faculty and peers. Importantly, teaching on boundary-setting was absent from the formal curriculum, however participants independently developed reflective practices to cultivate these skills. Moreover, we identified two operating discourses of the 'good doctor': an institutionalised discourse of the 'able doctor' and a counterdiscourse of the 'doctor with lived experience' which created a space for reframing experiences with illness and disability as a source of expertise rather than a source of stigma. Perspectives on the 'good doctor' carry important implications for how we define professional roles, and hold profound consequences for medical school admissions, curricular teaching and licensure. Medical students with lived experiences of illness and disability offer critical insights about curricular messages of the 'good doctor' based on their experiences as patients, providing important considerations for curriculum and faculty development.

Disability, program access, empathy and burnout in US medical students: A national study.

OBJECTIVE: The objective of this study is to investigate whether self-disclosed disability and self-reported program access are associated with measures of empathy and burnout in a national sample of US medical students. METHODS: The authors obtained data from students who responded to the Association of Medical Colleges (AAMC) Year 2 Questionnaire (Y2Q) in 2019 and 2020. Data included demographic characteristics, personal variables, learning environment indicators, measures of burnout (Oldenburg Burnout Inventory for Medical Students), empathy (Interpersonal Reactivity Index) and disability-related questions, including self-reported disability, disability category and program access. Associations between disability status, program access, empathy and burnout were assessed using multivariable logistic regression models accounting for YQ2 demographic, personal-related and learning environment measures. RESULTS: Overall, 23 898 (54.2%) provided disability data and were included. Of those, 2438 (10.2%) self-reported a disability. Most medical students with disabilities (SWD) self-reported having program access through accommodations (1215 [49.8%]) or that accommodations were not required for access (824 [33.8%]). Multivariable models identified that compared with students without disabilities, SWD with and without program access presented higher odds of high exhaustion (1.50 [95% CI, 1.34-1.69] and 2.59 [95% CI, 1.93-3.49], respectively) and lower odds of low empathy (0.75 [95% CI, 0.67-.85] and 0.68 [95% CI, 0.52-0.90], respectively). In contrast, multivariable models for disengagement identified that SWD reporting lack of program access presented higher odds of high disengagement compared to students without disabilities (1.43 [95% CI, 1.09-1.87], whereas SWD with program access did not (1.09 [95% CI, 0.97-1.22]). CONCLUSIONS: Despite higher odds of high exhaustion, SWD were less likely to present low empathy regardless of program access, and SWD with program access did not differ from students without disabilities in terms of disengagement. These findings add to our understanding of the characteristics and experiences of SWD including their contributions as empathic future physicians.

Institutional Accountability for Students With Disabilities: A Call for Liaison Committee on Medical Education Action.

Medical educators and leaders have called for greater diversity among the physician workforce, including those with disabilities. However, many students with disabilities are precluded from entering and completing medical training due to historically restrictive technical standards and poor internal practices to protect student privacy. This limits the possibilities for growing this part of the workforce and making progress toward the ultimate goal of having a physician workforce that better represents the patients it serves. To achieve diversity among the physician workforce, medical education must create environments that allow students with disabilities to apply to, flourish in, and feel well supported in medical school. Recent additions to Accreditation Council for Graduate Medical Education requirements have helped to catalyze work in the area of disability inclusion by incorporating disability-focused mandates into graduate medical education accreditation standards. However, similar mandates for undergraduate medical education have not yet materialized. In this article, the authors call for the Liaison Committee on Medical Education (LCME) to elevate disability as a valued part of medical school diversity in its accreditation standards and to include protections for disabled students. The authors propose that the LCME can take 5 actions to promote institutional accountability toward students with disabilities: (1) define disability as diversity, (2) mandate disability support, (3) protect from conflicts of interest, (4) protect privacy, and (5) verify schools' technical standards comply with the Americans with Disabilities Act. By adopting these recommendations, the LCME would send the powerful message that students with disabilities bring welcome expertise and value to the medical community.

Structural Barriers to Student Disability Disclosure in US-Allopathic Medical Schools.

INTRODUCTION: Leaders in medical education have expressed a commitment to increase medical student diversity, including those with disabilities. Despite this commitment there exists a large gap in the number of medical students self-reporting disability in anonymous demographic surveys and those willing to disclose and request accommodations at a school level. Structural elements for disclosing and requesting disability accommodations have been identified as a main barrier for students with disabilities in medical education, yet school-level practices for student disclosure at US-MD programs have not been studied. METHODS: In August 2020, a survey seeking to ascertain institutional disability disclosure structure was sent to student affairs deans at LCME fully accredited medical schools. Survey responses were coded according to their alignment with considerations from the AAMC report on disability and analyzed for any associations with the AAMC Organizational Characteristics Database and class size. RESULTS: Disability disclosure structures were collected for 98 of 141 eligible schools (70% response rate). Structures for disability disclosure varied among the 98 respondent schools. Sixty-four (65%) programs maintained a disability disclosure structure in alignment with AAMC considerations; 34 (35%) did not. No statistically significant relationships were identified between disability disclosure structures and AAMC organizational characteristics or class size. DISCUSSION: Thirty-five percent of LCME fully accredited MD program respondents continue to employ structures of disability disclosure that do not align with the considerations offered in the AAMC report. This structural non-alignment has been identified as a major barrier for medical students to accessing accommodations and may disincentivize disability disclosure. Meeting the stated calls for diversity will require schools to consider structural barriers that marginalize students with disabilities and make appropriate adjustments to their services to improve access.

The Unexamined Diversity: Disability Policies and Practices in US Graduate Medical Education Programs.

BACKGROUND: Graduate medical education (GME) institutions must ensure equal access for trainees with disabilities through appropriate and reasonable accommodations and policies. To date, no comprehensive review of the availability and inclusiveness of GME policies for residents with disabilities exists. OBJECTIVE: We examined institutions' compliance with Accreditation Council for Graduate Medical Education (ACGME) requirements and alignment with Association of American Medical Colleges (AAMC) policy considerations. METHODS: Between June and August 2019, we conducted a directed content analysis of GME institutional policies using the AAMC report on disability considerations and the ACGME institutional requirements as a framework. RESULTS: Of the 47 GME handbooks available for review, 32 (68%) included a disability policy. Forty-one of the 47 (87%) handbooks maintained a nondiscrimination statement that included disability. Twelve of the 32 (38%) handbooks included a specific disability policy and language that encouraged disclosure, and 17 (53%) included a statement about the confidential documentation used to determine reasonable accommodations. Nineteen of the 32 (59%) maintained a clear procedure for disclosing disabilities and requesting accommodations. CONCLUSIONS: While disability policies are present in many of the largest GME institutions, it is not yet a standardized practice. For institutions maintaining a disability policy, many lack key elements identified as best practices in the AAMC considerations.

Should Wellness Be a Core Competency for Physicians?

There has been a recent rise in calls for action around wellness and physician health. In medical education, wellness has been proposed as a physician competency. In this article, the authors review the history of the "wellness as a competency" concept within U.S. and Canadian residency programs and medical schools. Drawing from literature on the discourses of wellness and competence in medical education, they argue that operationalizing wellness as a physician competency holds profound implications for curricula, admissions, evaluation, and licensure. While many definitions of "wellness" and "competency" are used within medical training environments, the authors argue that the definitions institutions ultimately use will have significant impacts for trainees who are considered "unwell." In particular, medical learners with disabilities-including those with mental health, chronic health, learning, sensory, and mobility disabilities-may not conform to dominant conceptions of "wellness," and there is a risk they will become further stigmatized or even be considered unsuitable to practice in the profession. The authors conclude that framing wellness as a competency has the potential to legitimize support-seeking and prioritize physician health, yet it may also have the potential unintended effect of excluding certain learners from the profession. They propose a universal design approach to understand wellness at a systems level and to remove barriers to wellness for all medical learners.

A Lexicon of Concepts of Humanistic Medicine: Exploring Different Meanings of Caring and Compassion at One Organization.

PURPOSE: There has been scant scholarly attention paid to characterizing how the numerous definitions of terms associated with compassion and humanism have been mobilized or what the organizational implications of pursuing different constructs might be. This study explored the uses and implications of the terminology associated with humanistic medicine in the work of the Associated Medical Services (AMS) Phoenix Project. METHOD: This study involved two phases (2014-2015). First, two pilot group workshops with AMS Phoenix Project participants and stakeholders were conducted to explore ways of parsing and interpreting core concepts used in the project. The authors then assembled an archive of texts associated with the project, comprising the project website and blog posts, conference proceedings, and fellowship and grant applications. Informed by critical discourse analysis, the authors identified, described, and analyzed core terms related to the project's mission and explored the type of health care practices and reforms implied by their use. RESULTS: Two recurring core terms, care/caring and compassion, and eight clusters of terms related to these core terms were identified in the archive. Caring and compassion as terms were articulated in various psychological, sociological, and political configurations. This polysemy reflected a diverse array of health care reform agendas. CONCLUSIONS: Understanding how different interpretations of caring and compassion cluster around core topics and concerns of humanistic medicine offers scholars an entry point for comparing and appraising the quality and direction of reform agendas, including multilevel strategies that involve systems-level changes.

"Being on Both Sides": Canadian Medical Students' Experiences With Disability, the Hidden Curriculum, and Professional Identity Construction.

PURPOSE: Medical students with disabilities hold firsthand knowledge as health care recipients, yet face barriers to disclosure and support. Their experiences provide a unique lens for understanding professional identity construction; this study explored how disabled medical students experience training as both patients and trainees. METHOD: The authors conducted qualitative interviews with 10 medical students at the University of Toronto Faculty of Medicine with self-identified disabilities. They performed textual analysis of documents concerning medical student wellness from 13 Canadian universities, including policies, student services, and student blogs (July 2016 to March 2017). Using principles of critical discourse analysis, the authors coded the interviews and texts to identify operating discourses and core themes, drawing from sociocultural theories of professional identity construction and the hidden curriculum. RESULTS: Two dominant discourses emerged from the interviews and texts, revealing institutionalized notions of the perceived "good student" and "good patient." These roles held contradictory demands, demonstrating how institutions often implicitly and explicitly framed wellness as a means to optimal academic performance. Two additional themes, "identity compartmentalization" and "identity intersection," captured students' experiences navigating identities as patients and trainees. Although students lacked explicit opportunities to express their expertise as patients in the formal curriculum, their experiences in both roles led to improved communication, advocacy, and compassion. CONCLUSIONS: Institutional discourses around disability and academic performance hold material implications for curricular content, clinical teaching, and availability of supports in medical school. By repositioning students' experiences with disability as sources of expertise, this study highlights opportunities for teaching compassionate care.

Organizational stressors associated with job stress and burnout in correctional officers: a systematic review.

BACKGROUND: In adult correctional facilities, correctional officers (COs) are responsible for the safety and security of the facility in addition to aiding in offender rehabilitation and preventing recidivism. COs experience higher rates of job stress and burnout that stem from organizational stressors, leading to negative outcomes for not only the CO but the organization as well. Effective interventions could aim at targeting organizational stressors in order to reduce these negative outcomes as well as COs' job stress and burnout. This paper fills a gap in the organizational stress literature among COs by systematically reviewing the relationship between organizational stressors and CO stress and burnout in adult correctional facilities. In doing so, the present review identifies areas that organizational interventions can target in order to reduce CO job stress and burnout. METHODS: A systematic search of the literature was conducted using Medline, PsycINFO, Criminal Justice Abstracts, and Sociological Abstracts. All retrieved articles were independently screened based on criteria developed a priori. All included articles underwent quality assessment. Organizational stressors were categorized according to Cooper and Marshall's (1976) model of job stress. RESULTS: The systematic review yielded 8 studies that met all inclusion and quality assessment criteria. The five categories of organizational stressors among correctional officers are: stressors intrinsic to the job, role in the organization, rewards at work, supervisory relationships at work and the organizational structure and climate. The organizational structure and climate was demonstrated to have the most consistent relationship with CO job stress and burnout. CONCLUSIONS: The results of this review indicate that the organizational structure and climate of correctional institutions has the most consistent relationship with COs' job stress and burnout. Limitations of the studies reviewed include the cross-sectional design and the use of varying measures for organizational stressors. The results of this review indicate that interventions should aim to improve the organizational structure and climate of the correctional facility by improving communication between management and COs.

Effective lifestyle interventions to improve type II diabetes self-management for those with schizophrenia or schizoaffective disorder: a systematic review.

BACKGROUND: The prevalence of type II diabetes among individuals suffering from schizophrenia or schizoaffective disorders is more than double that of the general population. By 2005, North American professional medical associations of Psychiatry, Diabetes, and Endocrinology responded by recommending continuous metabolic monitoring for this population to control complications from obesity and diabetes. However, these recommendations do not identify the types of effective treatment for people with schizophrenia who have type II diabetes. To fill this gap, this systematic evidence review identifies effective lifestyle interventions that enhance quality care in individuals who are suffering from type II diabetes and schizophrenia or other schizoaffective disorders. METHODS: A systematic search from Medline, CINAHL, PsycINFO, and ISI Web of Science was conducted. Of the 1810 unique papers that were retrieved, four met the inclusion/exclusion criteria and were analyzed. RESULTS: The results indicate that diabetes education is effective when it incorporates diet and exercise components, while using a design that addresses challenges such as cognition, motivation, and weight gain that may result from antipsychotics. CONCLUSIONS: This paper begins to point to effective interventions that will improve type II diabetes management for people with schizophrenia or other schizoaffective disorders.

In and out of consciousness: sustained electrophysiological activity reflects individual differences in perceptual awareness.

Although significant advances in our understanding of the cognitive and neural processes involved in conscious awareness have occurred in recent years, the precise mechanisms that support consciousness remain elusive. Examining the neural correlates associated with the moment a stimulus enters or exits conscious awareness is one way to potentially identify the neural mechanisms that give rise to consciousness. In the present study, we recorded neural activity using electroencephalography (EEG) while participants observed a bilateral shape-from-motion (SFM) display. While the display is in motion, the observer perceives an object that is immediately segregated from a noisy background. After the motion stops, the observer's experience of the object remains momentarily in awareness, before it eventually fades out of consciousness back into the noisy background. Consistent with subjective reports of perceptual experience, we observed a prominent sustained posterior contralateral negativity known as the contralateral delay activity (CDA). This activity was sustained only in conditions associated with sustained awareness. Interestingly, the amplitude of the CDA was correlated with individual differences in visual awareness, suggesting that this activity plays a significant role in the maintenance of objects in consciousness. The CDA is typically associated with visual short-term memory (VSTM), suggesting that conscious visual awareness may be mediated by the same neural and cognitive mechanisms that support VSTM. Our results demonstrate that the CDA may reflect the contents of conscious awareness, and therefore can provide a measure to track when information moves in and out of consciousness.

Interventions to improve work outcomes in work-related PTSD: a systematic review.

BACKGROUND: Posttraumatic stress disorder acquired at work can be debilitating both for workers and their employers. The disorder can result in increased sick leave, reduced productivity, and even unemployment. Furthermore, workers are especially unlikely to return to their previous place of employment after a traumatic incident at work because of the traumatic memories and symptoms of avoidance that typically accompany the disorder. Therefore, intervening in work-related PTSD becomes especially important in order to get workers back to the workplace. METHODS: A systematic literature search was conducted using Medline, PsycINFO, Embase, and Web of Science. The articles were independently screened based on inclusion and exclusion criteria, followed by a quality assessment of all included articles. RESULTS: The systematic search identified seven articles for inclusion in the review. These consisted of six research articles and one systematic review. The review focused specifically on interventions using real exposure techniques for anxiety disorders in the workplace. In the research articles addressed in the current review, study populations included police officers, public transportation workers, and employees injured at work. The studies examined the effectiveness of EMDR, cognitive-behavioural techniques, and an integrative therapy approach called brief eclectic psychotherapy. Interestingly, 2 of the 6 research articles addressed add-on treatments for workplace PTSD, which were designed to treat workers with PTSD who failed to respond to traditional evidence-based psychotherapy. CONCLUSIONS: Results of the current review suggest that work-related interventions show promise as effective strategies for promoting return to work in employees who acquired PTSD in the workplace. Further research is needed in this area to determine how different occupational groups with specific types of traumatic exposure might respond differently to work-tailored treatments.