What makes mentors thrive? An exploratory study of their satisfaction in undergraduate medical education.

BACKGROUND: Mentoring medical students with varied backgrounds and individual needs can be challenging. Mentors' satisfaction is likely to be important for the quality and sustainability of mentorships, especially in programs where the mentor has responsibility for facilitating a group of mentees. However, little is known about what influences mentors' satisfaction. The aim of this study was to measure mentors' self-reported satisfaction with the mentoring experience and to explore associations between satisfaction and its putative factors. METHODS: An online survey was sent out to all physician mentors in each of the three mentorship programs (UiT The Arctic University of Norway, the University of Bergen, and McGill University, graduation years 2013-2020, n = 461). Data were analyzed by descriptive statistics, dimension reduction, and linear regression. RESULTS: On a scale from 1 to 5, mean mentor satisfaction score at two Norwegian and one Canadian medical school was 4.55 (95% CI 4.47, 4.64). In a multilevel multivariate regression analysis, two predictors were significantly associated with mentors' satisfaction: (1) the perception that students found the group meetings valuable (ß = 0.186, 95% CI 0.021, 0.351, p = 0.027) and (2) mentors' perceived rewards (ß = 0.330, 95% CI 0.224, 0.437, p < 0.001). Perceived rewards included experiencing gratifying relationships with students, and mentors' perception of self-development. CONCLUSIONS: In this study, mentors appeared to be highly satisfied with their mentoring functions. Our findings suggest that mentors' overall satisfaction is closely linked to their experiences of fulfilling mentor-student relationships and personal and professional development. Interestingly, and perhaps contrary to commonly held assumptions, we found no association between mentor satisfaction and financial compensation. Furthermore, satisfaction was not associated with the provision of pre-assigned topics for discussions for mentor group meetings. We propose that the mentors' experienced psycho-social rewards, and their competence in establishing well-functioning group dynamics, should be areas of focus for faculty development.

Discovering clinical phronesis.

Phronesis is often described as a 'practical wisdom' adapted to the matters of everyday human life. Phronesis enables one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine, phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including in medicine. Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness, modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes 'Clinical phronesis' as a descriptor for its appearance and role in the daily practice of (exemplary) physicians.

Placebos and Metaphors.

The objective of this essay is to develop the argument that placebos are a species of metaphor and to demonstrate that an analysis of the figurative trope can help us elucidate the power of the placebo response. The cognitive and embodied responses to both metaphors and placebos stem from the transfer of meaning between two domains, each with rich allusive properties that in turn depend on highly ramified and interconnected neural webs. Metaphors and placebos require an appropriate cultural backdrop for their linguistic and cognitive work and are dependent on shared social forms of life. More specifically, metaphors rely on an intersubjective connection and imply that a relational entanglement between doctor and patient is necessary to the effect of placebos in the clinical setting.

An empirical and philosophical exploration of clinical practice.

BACKGROUND: Previous empirical work among physicians has led us to propose that clinical practice is experienced by clinicians as an engagement-in-the-clinical-situation. In this study, we pursue our exploration of clinical practice 'on its own terms' by turning to the experience of patients. METHODS: Phenomenological analysis of in-depth individual interviews with 8 patients. RESULTS: We describe the patient experience as a set of three motifs: the shock on the realization of the illness, the chaos of the health care environment, and the anchor point provided by an engaged physician. We draw on Heidegger's notion of solicitude to show that patients are actively ascertaining the physician's engagement in their care. CONCLUSIONS: These findings lead us to question the classical "dual discourse" of medicine that offers a dichotomous account of clinical practice as the addition of care to cure, art to science, humanism to technique, and person to medical case. We found no such distinctions in our empirical investigation of clinical practice. Rather, in our synthesis, practice appears as a unitary experience. The physician's solicitude for the patient entrains engagement in the clinical situation. Moreover, the solicitous, engaged physician constitutes an anchor point for the patient.

Engagement and practical wisdom in clinical practice: a phenomenological study.

In order to understand the lived experiences of physicians in clinical practice, we interviewed eleven expert, respected clinicians using a phenomenological interpretative methodology. We identified the essence of clinical practice as engagement. Engagement accounts for the daily routine of clinical work, as well as the necessity for the clinician to sometimes trespass common boundaries or limits. Personally engaged in the clinical situation, the clinician is able to create a space/time bubble within which the clinical encounter can unfold. Engagement provides an account of clinical practice as a unitary lived experience. This stands in stark contrast to the prevailing notion, referred to as a dual discourse, that describes medicine as the addition of humanism to science. Drawing on Aristotle's notion of phronesis and Sartre's definition of the situation, we illustrate how this novel perspective entwines clinical practice, the person of the clinician, and the clinician's situation.

Reflection in medical education: intellectual humility, discovery, and know-how.

Reflection has been proclaimed as a means to help physicians deal with medicine's inherent complexity and remedy many of the shortcomings of medical education. Yet, there is little agreement on the nature of reflection nor on how it should be taught and practiced. Emerging neuroscientific concepts suggest that human thought processes are largely nonconscious, in part inaccessible to introspection. Our knowledge of the world is fraught with uncertainty, ignorance and indeterminacy, and influenced by emotion, biases and illusions, including the illusion of not having illusions. Neuroscience also documents that lifelong learning processes may hone nonconscious cognition to high levels of sophistication, allowing rapid and precise perceptions, judgments and actions in complex situations. We argue that knowledge of mechanisms underlying human thought may be useful in designing educational programs to foster desired attributes such as curiosity, critical self-awareness and intuitive acumen in medical professionals. The juxtaposition of neuroscientific insights with ideas from Kant on reflective judgement, van Manen on tact, and Aristotle on phronésis, supports a concept of reflection that manifests as wise practice. We suggest that reflection in medical education should be (a) an imperative for educators seeking to guide learners to manage the complexity and "messiness" of medical practice, and (b) a role-modelling mode of medical practice characterized by self-correcting behaviors that culminate in good and right professional actions. An example illustrates reflective practice in the teaching and learning of physicianship.

Joining the Club.

The clinical environment of the hospital ward and clinic is where medical students become physicians by engaging with patients under the tutelage of clinician teachers. These formative experiences guide the students' regard and respect for patients, shape their nascent medical identities, and influence their confidence in their chosen profession. This essay is grounded in an exegesis of narratives proffered by senior medical students during a selective course on the language of medicine. These stories reveal the affinity of students for their patients and their sensitivity to inappropriate behaviors by physicians and other caregivers. By contrast, observing role models who enact respect for patients reinforces the natural regard of students towards patients as persons and engenders respect of students for their teachers. Students grapple with moral dilemmas that contribute to cognitive dissonance in their lived realities. They arrive at medical school with powerful and sometimes clear images of their calling as physicians yet encounter antithetical role models whose behaviors contradict their own evolving identities. In consequence, medical students may wonder whether entry to the club they are eager to join entails abandoning both their patients and their ideals.

The Humanities in Medical Education: Ways of Knowing, Doing and Being.

The personhood of the physician is a crucial element in accomplishing the goals of medicine. We review claims made on behalf of the humanities in guiding professional identity formation. We explore the dichotomy that has evolved, since the Renaissance, between the humanities and the natural sciences. The result of this evolution is an historic misconstrual, preoccupying educators and diverting them from the moral development of physicians. We propose a curricular framework based on the recovery of Aristotelian concepts that bridge identity and activity. The humanities and the natural sciences, jointly and severally, can fulfill developmental, characterological and instrumental purposes.

Teaching professionalism to first year medical students using video clips.

BACKGROUND: Medical schools are confronted with the challenge of teaching professionalism during medical training. The aim of this study was to examine medical students' perceptions of using video clips as a beneficial teaching tool to learn professionalism and other aspects of physicianship. METHODS: As part of the longitudinal Physician Apprenticeship course at McGill University, first year medical students viewed video clips from the television series ER. The study used qualitative description and thematic analysis to interpret responses to questionnaires, which explored the educational merits of this exercise. RESULTS: Completed questionnaires were submitted by 112 students from 21 small groups. A major theme concerned the students' perceptions of the utility of video clips as a teaching tool, and consisted of comments organized into 10 categories: "authenticity and believability", "thought provoking", "skills and approaches", "setting", "medium", "level of training", "mentorship", "experiential learning", "effectiveness" and "relevance to practice". Another major theme reflected the qualities of physicianship portrayed in video clips, and included seven categories: "patient-centeredness", "communication", "physician-patient relationship", "professionalism", "ethical behavior", "interprofessional practice" and "mentorship". CONCLUSIONS: This study demonstrated that students perceived the value of using video clips from a television series as a means of teaching professionalism and other aspects of physicianship.

George Engel's Epistemology of Clinical Practice.

George Engel's (1913-1999) biopsychosocial model, one of the most significant proposals for the renewal of medicine in the latter half of the 20th century, has been understood primarily as a multi-factorial approach to the etiology of disease and as a call to re-humanize clinical practice. This common reading of Engel's model misses the central aspect of his proposal, that the biopsychosocial model is an epistemology for clinical work. By stating the simple fact that the clinician is not dealing directly with a body, but first, and inevitably, with a person, Engel challenged the epistemology implicit in the classical clinical method-a method predicated on the possibility of direct access to the body. Framed in epistemological terms, the issue at stake is not the need to complement medical science with humane virtues, but rather to acknowledge that the object of clinical practice is not the body but the patient.

The foundation of physicianship.

Although the practice of medicine continually changes in response to new biomedical understanding, novel technologies, and evolving cultural contexts, the ethical foundations of the clinical relationship between patient and physician paradoxically remain constant. There are fundamental characteristics with respect to character, behavior, and responsibilities that are descriptive of and necessary to the role of healer and that underpin the notion of physicianship. This article discusses the underlying characteristics or virtues that are necessary to the practice of medicine from the perspectives of three different philosophic traditions: the Aristotelian idea of phronesis as developed in the work of Edmund Pellegrino; the notion of alterity as framed by Emmanuel Levinas; and the attributes necessary to healing as laid out in the kabbala.

A faculty development workshop in narrative-based reflective writing.

Narrative approaches are used increasingly in the health professions with a range of objectives. We must acquaint educators with this burgeoning field and prepare them for the incorporation of story-telling in their pedagogical practices. The authors describe a template for a faculty development workshop designed to foster self-reflection through the use of narrative techniques and prepare clinical teachers to deploy such approaches. The design is based on a six-year experience in delivering introductory workshops in narrative approaches to medical teachers. The workshops, which served as a model for the template, have been offered to a total of 92 clinicians being trained to mentor medical students. A generic template is described. It includes a table of core concepts from narrative theory, a set of probing questions useful in a basic technical analysis of texts and a list of initiating prompts for exercises in reflective writing. A workshop organized and deployed using this template is deliverable over a half-day. The model has proven to be feasible and highly valued by participants. It can be adapted for other contexts by educators across the continuum of health professional education.

Teaching clinical thinking to first-year medical students.

BACKGROUND: The ability to think clearly and critically is necessary to normal human conduct. Particular forms of reasoning characteristic of practitioners of medicine have been studied, but a principled pedagogical framework that also reflects clinical practice has not been delineated. AIMS: The goals are: identify the principles that underlie the clinical thinking of physicians, develop a pedagogical framework, and design and implement curricular modules for medical students in the first year of their studies. METHODS: The authors reviewed prior work on clinical thinking of physicians and medical students as well as reflective pieces by seasoned clinicians. They also examined modalities of logic and inference used by physicians and others. The designed modules were implemented at the Faculty of Medicine at McGill University and linked to training in attentive listening and clinical observation. RESULTS: Five core features of a pedagogic framework on clinical thinking were developed and used to design and implement a series of teaching modules for first-year medical students. CONCLUSIONS: The core features, and the modules based upon them, can serve for further empirical work on clinical reasoning and lead to modules for advanced students as they progress in their acquisition of expertize.

Preparing medical students to become attentive listeners.

BACKGROUND: The ability to listen is critically important to many human endeavors and is the object of scholarly inquiry by a large variety of disciplines. While the characteristics of active listening skills in clinical practice have been elucidated previously, a cohesive set of principles to frame the teaching of these skills at the undergraduate medical level has not been described. AIMS: The purpose of this study was to identify the principles that underlie the teaching of listening to medical students. We term this capacity, attentive listening. METHODS: The authors relied extensively on prior work that clarified how language works in encounters between patients and physicians. They also conducted a review of the applicable medical literature and consulted with experts in applied linguistics and narrative theory. RESULTS: They developed a set of eight core principles of attentive listening. These were then used to design specific teaching modules in the context of curriculum renewal at the Faculty of Medicine, McGill University. CONCLUSIONS: Principles that are pragmatic in nature and applicable to medical education have been developed and successfully deployed in an undergraduate medical curriculum.

Preparing medical students to become skilled at clinical observation.

BACKGROUND: Observation is a fundamental skill for physicians and it is has been the subject of a resurgent interest. Although strategies for teaching observation have been described previously, many of them linked conceptually to emerging insights in visual literacy and aesthetic development, principles of clinical observation have not been elucidated. AIMS: The purpose of this study was to develop a set of principles that would be useful in guiding educators teach medical students how to observe. METHODS: The authors conducted a comprehensive review of the literature on the history and theory of clinical observation. They then consulted a group of individuals from a highly diverse background who, based on the nature of their work, were considered to have expertise in observation. RESULTS: Informed by the literature and the group of experts, the authors developed a set of four guiding principles relating to pedagogy and eight core principles of clinical observation. In the context of curriculum renewal at the Faculty of Medicine, McGill University, these principles were then used to create specific teaching modules. CONCLUSIONS: Principles that are pragmatic in nature, anchored in a theoretical framework of visual competence and applicable to medical education have been developed and successfully deployed.

A healing curriculum.

CONTEXT: The banner of patient-centredness flies over many academic institutions; however, the practice and teaching of medicine remain oriented to disease. This incongruence is the result of an original Flexnerian dichotomy between the basic and clinical sciences and is maintained by a more recent distinction between disease and illness. One mind-set emphasises basic science and pathology pedagogically, whilst clinical medicine becomes a search for disease. The second introduces the patient as the focal point, underlining the personal and social contexts of illness. RESPONSE AT A CONCEPTUAL LEVEL: We must orient ourselves to a single central theme, namely, the well-being of the individual patient. Doing so does not deny the importance of the scientific understanding of biological function. Indeed, recent advances in genetics may permit a richer view of the individual as a unique product of genetic, developmental and experiential forces. The foregoing provide a coherent framework for a scientifically guided and humanistic medicine, which replaces the false dichotomies that have plagued medical school curricula with a congruent and stereoscopic view of medical education. RESPONSE AT A CURRICULAR LEVEL: We describe an undergraduate programme, entitled 'Physicianship', based on the fundamental premise that healing is the doctor's primary obligation. Explicit training in a specific clinical method, whose cardinal features include observation, attentive listening and clinical reasoning, emphasises the knowledge and skills necessary to effect this theoretical framework. The understanding of illnesses emphasises loss of homeostasis, whereas the physical examination highlights impairments of function. The educational experience is enriched with numerous opportunities for self-reflection.

Faculty development as an instrument of change: a case study on teaching professionalism.

Faculty development includes those activities that are designed to renew or assist faculty in their different roles. As such, it encompasses a wide variety of interventions to help individual faculty members improve their skills. However, it can also be used as a tool to engage faculty in the process of institutional change. The Faculty of Medicine at McGill University determined that such a change was necessary to effectively teach and evaluate professionalism at the undergraduate level, and a faculty development program on professionalism helped to bring about the desired curricular change. The authors describe that program to illustrate how faculty development can serve as a useful instrument in the process of change. The ongoing program, established in 1997, consists of medical education rounds and "think tanks" to promote faculty consensus and buy-in, and diverse faculty-wide and departmental workshops to convey core content, examine teaching and evaluation strategies, and promote reflection and self-awareness. To analyze the approach used and the results achieved, the authors applied a well-known model by J.P. Kotter for implementing change that consists of the following phases: establishing a sense of urgency, forming a powerful guiding coalition, creating a vision, communicating the vision, empowering others to act on the vision, generating short-term wins, consolidating gains and producing more change, and anchoring new approaches in the culture. The authors hope that their school's experience will be useful to others who seek institutional change via faculty development.