Investigating Medical Students' Navigation of Ethical Dilemmas: Understanding the Breakdown and How to Solve It.

PURPOSE: Medical students receive a varying amount of training in medical ethics and are expected to navigate clinical ethical dilemmas innately. There is little literature on attempts to navigate ethical dilemmas experienced during early clinical experiences and whether current curricula prepare students for these dilemmas. This study explores the different ethical dilemmas experienced by medical students on their third-year clerkships and analyzes the factors, sources, and resolutions proposed by them. METHODS: From 2016 to 2018, third-year medical students completed a written assignment to describe, analyze, and reflect on a clinical situation in which they experienced an ethical dilemma. They identified specific ethical dilemmas present, potential preventative and aftermath solutions, and reflected on their professional development from their experience. The research team utilized applied thematic analysis to identify themes and patterns in the data. A thematic matrix was utilized to examine similarities and differences across medical students. RESULTS: Of the 162 reflections, 144 (88.9%) students indicated an ethical dilemma that included issues related to autonomy and beneficence. Of these, 116 (71.6%) students found the two ethical principles in direct conflict. Students identified three common sources of this conflict: lack of communication; unclear understanding of clinical policies regarding family authority and psychiatric capacity; and medical negligence. Lastly, students suggested different solutions for dealing with and preventing this conflict. CONCLUSION: Our findings suggest that an overwhelming number of students face ethical challenges when confronted with medical situations that raise conflicts between autonomy and beneficence. Their recommended solutions reveal an appeal among students to have tools and strategies in place to ease the need to make difficult decisions. Medical students might be better served by learning about the complexities of ethical decision-making and the likelihood of experiencing moral distress when they feel an inability to implement what they envision as the best solution.

Health Care Use, Coverage, and Experiences During the Year Prior to Pregnancy in a Primarily Hispanic Population with Low Income: A Descriptive Qualitative Study.

INTRODUCTION: A qualitative picture of the health care experiences prior to pregnancy can inform patient-centered strategies to optimize preconception health. This study describes health care utilization and experiences and how health care costs were covered in the year prior to pregnancy in a population of primarily Hispanic women with low income. METHODS: Pregnant participants were recruited from 5 Federally Qualified Health Center clinics. Semistructured interviews included questions about health care in the year prior to pregnancy. Transcripts were analyzed using a thematic approach that integrated deductive and inductive analysis. RESULTS: Most participants self-identified as Hispanic. Just under half were US citizens. All but one were Medicaid or Children's Health Insurance Program Perinatal coverage insurance during pregnancy and relied on a variety of strategies to cover prepregnancy health care costs. Almost all received health care during the year prior to pregnancy. Fewer than half reported an annual preventive visit. Health care needs that led to care-seeking included a prior pregnancy, chronic depression, contraception, workplace injury, a persistent rash, screening and treatment for sexually transmitted infection, breast pain, stomach pain (leading to gallbladder removal), and kidney infection. The ways in which study participants covered the costs of health care ranged in terms of sources and complexity. Although some participants described stable health care coverage, most reported changes throughout the year as they pieced together various health care coverage programs and out-of-pocket payments. When participants did seek health care prior to their current pregnancy, most described the experience in positive terms and focused on health care provider communication quality. Respect of patient autonomy was highly valued. DISCUSSION: Women with pregnancy-related health care coverage accessed care for a wide range of health care needs prior to pregnancy. Health care providers may consider strategies to respectfully introduce preconception care into any visit by an individual who could become pregnant.

Understanding the primary health care experiences of individuals who are homeless in non-traditional clinic settings.

BACKGROUND: Despite the widespread implementation of Health Care for the Homeless programs that focus on comprehensive, integrated delivery systems of health care for people experiencing homelessness, engaging and retaining people experiencing homelessness in primary care remains a challenge. Few studies have looked at the primary care delivery model in non-traditional health care settings to understand the facilitators and barriers to engagement in care. The objective of our study was to explore the clinic encounters of individuals experiencing homelessness receiving care at two different sites served under a single Health Care for the Homeless program. METHODS: Semi-structured interviews were conducted with people experiencing homelessness for an explorative qualitative study. We used convenience sampling to recruit participants who were engaged in primary care at one of two sites: a shelter clinic, n = 16, and a mobile clinic located in a church, n = 15. We then used an iterative, thematic approach to identify emergent themes and further mapped these onto the Capability-Opportunity-Motivation model. RESULTS: Care accessibility, quality and integration were themes that were often identified by participants as being important facilitators to care. Psychological capability and capacity became important barriers to care in instances when patients had issues with memory or difficulty with perceiving psychological safety in healthcare settings. Motivation for engaging and continuing in care often came from a team of health care providers using shared decision-making with the patient to facilitate change. CONCLUSION: To optimize health care for people experiencing homelessness, clinical interventions should: (1) utilize shared-decision making during the visit, (2) foster a sense of trust, compassion, and acceptance, (3) emphasize continuity of care, including consistent providers and staff, and (4) integrate social services into Health Care for the Homeless sites.

System Dynamics of Cognitive Vulnerabilities and Family Support Among Latina Children and Adolescents.

The paper describes an approach to developing a data-driven development of a feedback theory of cognitive vulnerabilities and family support focused on understanding the dynamics experienced among Latina children, adolescents, and families. Family support is understood to be a response to avoidant and maladaptive behaviors that may be characteristic of cognitive vulnerabilities commonly associated depression and suicidal ideation. A formal feedback theory is developed, appraised, and analyzed using a combination of secondary analysis of qualitative interviews (N = 30) and quantitative analysis using system dynamics modeling and simulation. Implications for prevention practice, treatment, and future research are discussed.

Father-Daughter Relationships among Latina Adolescents Who Attempted Suicide: An Exploratory Dyadic Analysis.

Among adolescents, Latinas are at an increased risk of experiencing suicidal ideation and attempts compared to non-Hispanic, White youth. Previous research indicates that family dynamics are influential as both protective and risk factors. Although significant research has been conducted over the past several decades examining the mother-daughter relationship, few studies have examined the father-daughter relationship among Latina adolescent suicide attempters. The relationship dynamics between fathers and daughters of Latina descent are both similar and unique compared to mother-daughter relationships. Given this, an in-depth analysis is warranted. To address this gap, the present study utilized dyadic thematic analysis to describe father-daughter relationships (N = 10 dyads, 20 individual interviews) and fathers' reactions to their Latina daughters' suicide attempt(s). Three themes emerged from the results (a) dynamic proximity, which describes the variation in emotional and physical closeness between fathers and daughters; (b) father as protector, which describes fathers' roles in protecting or failing to protect their daughters; (c) responses to the suicide attempt, which describes the various ways fathers responded to daughters' suicide attempts, ranging from helpful action to apathy. Themes gleaned from in-depth interviews informed a deeper understanding of these complex, multifaceted relationships, and how they may be linked to fathers' responses to daughters' suicide attempts. Implications for future research and clinical practice with youth at risk for suicidal ideations and behaviors, along with the impact of such experiences on families, are discussed.

Entre las adolescentes, las latinas corren un mayor riesgo de tener ideación e intentos suicidas en comparación con las jóvenes blancas no hispanas. Hay investigaciones previas que indican que la dinámica familiar influye tanto como factor protector como de riesgo. Aunque se ha investigado bastante durante las últimas décadas sobre la relación entre madre e hija, en pocos estudios se ha examinado la relación entre padre e hija en adolescentes latinas que han intentado suicidarse. La dinámica de la relación entre padres e hijas de ascendencia latina es tanto similar como única en comparación con la de la relación entre madres e hijas. En virtud de esto, es necesario un análisis profundo. Para subsanar esta carencia, en el presente estudio se utilizó el análisis temático diádico para describir las relaciones entre padres e hijas (N = 10 díadas, 20 entrevistas individuales) y las reacciones de los padres a los intentos de suicidio de sus hijas latinas. De los resultados surgieron tres temas: (a) la proximidad dinámica, que describe la variación en la cercanía emocional y física ente los padres y las hijas; (b) el padre como protector, que describe los roles de los padres a la hora de proteger o no proteger a sus hijas; (c) las respuestas al intento de suicidio, que describe las diversas maneras en las que los padres respondieron a los intentos de suicidio de las hijas, las cuales variaron desde medidas de ayuda hasta apatía. Los temas obtenidos de entrevistas detalladas informaron una mayor comprensión de estas relaciones complejas y multifacéticas, y de cómo pueden vincularse con las respuestas de los padres a los intentos de suicidio de las hijas. Se debaten las consecuencias para futuras investigaciones y para la práctica clínica con las jóvenes en riesgo de ideaciones y conductas suicidas, así como el efecto de dichas experiencias en las familias.

Sibling relationships among U.S. citizen children of undocumented Mexican parents.

Current U.S. immigration policies disproportionately impact Mexican-origin mixed-status families, yet few studies examine the consequences of immigration enforcement (e.g., immigration-related arrest and detention) and deportation on sibling dynamics. Given this gap, this study focuses on the experiences and changes within sibling relationships in the aftermath of parental detention and deportation. We analyzed a subsample of 20 citizen children interviews (7 sibling dyads; 2 sibling triads) from a multi-site binational study that examined the psychosocial functioning of U.S. citizen children with undocumented Mexican parents. Using inductive thematic analysis, we explored the roles and functional importance of sibling relationships before and after experiences of parents' detention and deportation. Our findings suggest that prior to detention or deportation experiences, sibling relationships were described as "normal." After these experiences, however, sibling relationships changed and developed protective adaptations, including more open communication about their experiences and the assumption of caregiving roles. In cases where deportation did not occur, there still existed the threat of future immigration-related action, which contributed to fear and an inability to share feelings and experiences among siblings. Our findings suggest that sibling relationships might serve as an important locus of stability and protection. Yet, adaptive communication may not emerge as long as the threat of apprehension, detention, and deportation exists.

Las políticas migratorias actuales de los Estados Unidos afectan de manera desproporcionada a las familias de condición migratoria mixta de origen mexicano, sin embargo, pocos estudios analizan las consecuencias de la aplicación de las leyes de inmigración (por ej.: el arresto y la detención relacionados con la inmigración) y la deportación en la dinámica fraternal. Teniendo en cuenta esta falta de datos, el presente estudio se centra en las experiencias y los cambios dentro de las relaciones fraternales después de la detención y la deportación de los padres. Analizamos una submuestra de 20 entrevistas a niños ciudadanos (7 díadas de hermanos; 2 tríadas de hermanos) de un estudio binacional realizado en varios sitios que analizó el funcionamiento psicosocial de niños ciudadanos de los Estados Unidos con padres mexicanos indocumentados. Utilizando el análisis temático inductivo, analizamos los roles y la importancia funcional de las relaciones fraternales antes y después de las experiencias de detención y deportación de los padres. Nuestros resultados indican que, antes de las experiencias de detención o deportación, las relaciones fraternales se describieron como "normales". Sin embargo, después de estas experiencias, las relaciones fraternales cambiaron y surgieron adaptaciones protectoras, por ejemplo, una comunicación más abierta acerca de sus experiencias y la asunción de roles de cuidado. En los casos donde no hubo deportación, igualmente existió la amenaza de una futura acción relacionada con la inmigración, la cual generó miedo e incapacidad de compartir sentimientos y experiencias entre hermanos. Nuestros resultados sugieren que las relaciones fraternales podrían servir como lugar importante de estabilidad y protección. Sin embargo, es posible que la comunicación adaptativa no surja mientras exista la amenaza de arresto, detención y deportación.

Trajectories of Well-Being Among Latina Adolescents Who Attempt Suicide: A Longitudinal Qualitative Analysis.

Significant research questions persist regarding the short- and long-term outcomes of Latina adolescents who attempt suicide. To address these limitations, we utilize an ecodevelopmental framework to identify potential factors that shape differential outcomes following a suicide attempt. Through an exploratory, longitudinal, qualitative research design, we investigate two research questions: How do trajectories of well-being vary among Latina teens after a suicide attempt? What risk and protective factors might contribute to different trajectories? We conducted qualitative interviews with 17 Latina participants living in predominantly low-income households in New York City. Interviews took place within the 6 months following their suicide attempts, and again, 12 months later. Analysis revealed three distinct trajectories after a suicide attempt: resilience, tenuous growth, and chronic stress. Our findings elucidate potential factors that contribute to resilience following a suicide attempt and underscore the importance of prevention and intervention programs that foster adolescents' connectivity across ecodevelopmental contexts.

Interdisciplinary Perspectives on an Integrated Behavioral Health Model of Psychiatry in Pediatric Primary Care: A Community-Based Participatory Research Study.

Integrated behavioral health services have positive outcomes for patients and providers, but little is known about providers' perspectives on implementing these services. This community-based participatory research collaboration with a Federally Qualified Health Center examined provider perspectives on implementing a collaborative psychiatry consultation program in pediatric primary care. We interviewed providers (N = 14) from psychiatry, social work, primary care, and psychology regarding their experiences implementing the program, and their recommendations for its sustainability. Providers described interdisciplinary integration arising from the program, with accompanying benefits (e.g., increased access to care for patients with complex diagnostic profiles, increased learning and role satisfaction among providers), and challenges (e.g., increased burden on primary care providers, potential patient discomfort with team-based care). Our results highlight the complexities of implementing collaborative psychiatry consultation in pediatric primary care, and suggest the importance of supporting primary care providers and patients within this context.

"Because That's the Culture": Providers' Perspectives on the Mental Health of Latino Immigrant Youth.

Immigrant youth experience a combination of stressors, such as isolation and discrimination, that put them at a greater risk for negative mental health outcomes. Relying on interviews with 24 service providers who work with Latino immigrant youth, this article examines how they construct and intervene in the worlds of immigrant youth to improve youth's mental health outcomes. Inductive thematic analysis revealed providers' reliance on cultural interpretations of the psychosocial circumstances facing immigrant youth. Providers alternated between drawing on discourses that reproduced stereotypes, assumptions, and biases, while simultaneously striving to transcend sociocultural differences to focus on the lived experiences of their clients. Although providers acknowledged the importance of structural barriers, such as poverty and discrimination, they "bracketed" these issues when recommending interventions. The article highlights that as cultural competence increasingly becomes part of social services, this professional discourse may distract providers' attention from more relevant targets of intervention.

Social support under siege: An analysis of forced migration among women from the Democratic Republic of Congo.

In 2016, researchers conducted a qualitative study in a mid-sized town in the United States to address gaps in research and practice related to psychosocial consequences of forced migration among women. The loss of social support and its impacts on the well-being of women are rarely addressed in refugee resettlement policy or practice overwhelmingly concerned with economic self-sufficiency. The study sought to develop theory to explain how women (n = 27) who migrated from the Democratic Republic of the Congo recreate social support post-resettlement in the United States. An interpretive approach informed by postcolonial feminist perspectives guided the grounded theory methodology. A theoretical model emerged explaining pivots in the internal and relational lives of women as social support systematically constricted over time as a result of war, displacement, and resettlement. Upon arrival to the United States, women experienced partitioned lives through changing relationships to space and time, which contributed to women being alone and impacted well-being. Converging processes propelled women towards learning to stand alone, through which women could develop a sense self-reliance, but not without internal and relational consequences. The analysis contributes to the empirical literature knowledge of how resettlement is a life altering event that sets into motion psychosocial processes with implications for well-being and health. Implications for practice and future research are discussed.

Transformative Possibilities: Politics and Cosmetic Surgery in the Bolivarian Revolution.

I examine the intersection of politics and aesthetics in a public hospital in Caracas, Venezuela in the first years of the twenty-first century. Given Venezuela's long-standing embrace of physical enhancement and the contradictions of the medical values of cosmetic surgery with those of Bolivarian socialism, the changing surgical practices at a well-established public site offer a significant case for considering how different actors negotiate the dialectics of care. In the face of increasing resource shortages, negotiations of aesthetic care contributed to tensions in the clinical encounter as patients creatively pushed Bolivarian policies to support their pursuits of aesthetic self-improvement.

Sense of Belonging and Youth Suicidal Behaviors: What Do Communities and Schools Have to Do with It?

Situating Thomas Joiner's concept of belonging within an ecological perspective, this study examined the associations between school and community belonging and suicidal ideation and attempts among high school students. The study used data from the 2013 Texas Youth Risk Behavior Survey (N = 2,560). Results demonstrated that community belonging reduced the odds of youth suicidal behaviors. School bullying, feeling unsafe at school, and being threatened or injured at a school increased the odds of suicidal behaviors. Findings suggest that fostering safe and inclusive environments and strengthening youth's experiences of school and community belonging may reduce suicidal behaviors in high school youth.

Processes of Belonging for Citizen-Children of Undocumented Mexican Immigrants.

In this article, we focus on the developmental contexts of middle childhood and early adolescence to explore the lives of citizen-children living with undocumented Mexican parents. We draw on the concept of belonging to highlight the distinct situation of citizen-children and the ways in which they come to understand their place in a world. To capture the experiences of citizen-children born to undocumented Mexican immigrant parents and their sense of belonging to place and community, we conducted in-depth interviews with 83 citizen-children in late childhood and early adolescence in three groups. One group of citizen-children lived in Mexico after their parents' deportation. Another group remained in the U.S. after parents were detained or deported. The third group did not have a parent in deportation proceedings. Qualitative analyses of children's recorded interviews revealed their experiences of discovery of parents' undocumented status; political, social and material exclusion; and rupture of family ties. Children were keenly aware that birthright citizenship afforded them numerous privileges unavailable to their parents, but that it did not extend to the very privilege, they valued most: an intact family. The loss of parents through detention or deportation forced some children to consider existential questions about who they were and where they belonged, sometimes pitting family members against one another. Our findings suggest that belonging is intimately tied to broader forces of legal persecution that go beyond individualized notions of illegality and have deep, possibly lasting psychological effects.

Exploring the Effects of U.S. Immigration Enforcement on the Well-being of Citizen-Children in Mexican Immigrant Families.

In this article, we draw on ecocultural theories of risk and resilience to examine qualitatively the experiences of U.S. citizen-children living with their undocumented Mexican parents. Of central importance is the fact that citizen-children's daily lives are organized around the very real possibility that their undocumented parents could one day be detained and deported. Our purpose is to render visible the various ways in which citizen-children confront and navigate the possibilities-and realities-of parental deportation. We develop a framework to conceptualize the complex multidimensional, and often multidirectional, factors experienced by citizen-children vulnerable to or directly facing parental deportation. We situate youth well-being against a backdrop of multiple factors to understand how indirect and direct encounters with immigration enforcement, the mixed-status family niche, and access to resources shape differential child outcomes. In doing so, we offer insights into how different factors potentially contribute to resilience in the face of adversity.

An exploratory study of nonsuicidal self-injury and suicidal behaviors in adolescent Latinas.

To date, there is little research to validate empirically differences between nonsuicidal self-injurious behavior (NSSI) and attempted suicide among Latina adolescents. Understanding the characteristics and contextual features of self-harmful behaviors among Latina teens is a critical public health and social justice matter given the disproportionate rates of attempted suicide and anticipated population growth of this vulnerable group. In this article, we draw on an ecodevelopmental model to focus attention on factors in the sociocultural environment that shape suicidal behaviors and NSSIs. Through analysis of qualitative interviews conducted with girls who used NSSI (n = 18), attempted suicide (n = 29), used NSSI and attempted suicide (n = 8,) and had no reported lifetime history of self-harm (n = 28), we describe the sociocultural factors that shaped psychosocial vulnerabilities and gave rise to decisions to use NSSI or attempt suicide. Our analysis revealed that adolescents who engaged in NSSI perceived their negative feelings as something that could be controlled through self-injurious acts, whereas powerlessness was a theme underlying the emotional states of girls who attempted suicide. When NSSI ceased to function as a mechanism for control, girls came to sudden decisions to attempt suicide. Most teens identified specific, and often multiple, situations that induced intense affective states and shaped decisions to inflict self-harm. Two situational experiences emerged as particularly salient and promising for subsequent studies on self-harmful behaviors among Latina adolescents: transnational stress and bullying. We describe each of these and offer suggestions for future research and practice.

Examining the interplay among family, culture, and latina teen suicidal behavior.

In this article, we explore the relationships among culture, family, and attempted suicide by U.S. Latinas. We analyzed qualitative interviews conducted with Latina teen suicide attempters (n = 10) and their parents. We also incorporated data collected from adolescents with no reported history of self-harm (n = 10) and their parents to examine why some individuals turned to suicide under similar experiences of cultural conflict. Our results reveal that Latina teens who attempted suicide lacked the resources to forge meaningful social ties. Without the tools to bridge experiences of cultural contradiction, the girls in our study described feeling isolated and alone. Under such conditions, adolescents turned to behaviors aimed at self-destruction. Unlike their peers who attempted suicide, adolescent Latinas with no lifetime history of attempted suicide were able to mobilize resources in ways that balanced experiences of acculturative tension by creating supportive relationships with other individuals.

Embodying racism: race, rhinoplasty, and self-esteem in Venezuela.

In this article, I examine how race motivates women's decisions to undergo aesthetic rhinoplasty in Caracas, Venezuela. Through a combination of cultural domain analysis and thematic analysis of qualitative interviews, I explore how the preference for whiteness and associated facial features dovetail with the aesthetic ideals promoted by cosmetic surgeons. Rhinoplasty is offered by physicians and interpreted by patients as a resolution to body dissatisfaction and low self-esteem. The clinical ethos of objectivity established by cosmetic surgeons fails to acknowledge how perceptions of the self and body are strongly tied to racial marginalization: patients' efforts to alter the nose reveal attempts to change not only how the body looks, but how it is lived. As a result, cosmetic surgery only acts as a stop-gap measure to heighten one's self-esteem and body image.

Are suicide attempts by young Latinas a cultural idiom of distress?

The high rates of suicide attempts among adolescent Hispanic females in the United States have been well established by epidemiological and clinical studies. In this paper, we review the research history of Latina suicide attempts and their characteristics. Then we apply multi-faceted conceptual and empirical criteria found in the anthropological and psychiatric literature about cultural idioms of distress to the suicide attempts of young Latinas. We contrast the suicide-attempt phenomenon to the well-known ataque de nervios and propose that the phenomenon may reflect a developmental or cultural variant of the ataque. The attempt-as-idiom proposition is intended to invite discussion that can deepen our understanding of the cultural roots of the suicide attempts and their possible designation as cultural idiom. Establishing the meaning of suicide attempts within a cultural perspective can assist psychological and psychiatric research and clinical interventions.

Family Relationships and Latina Teen Suicide Attempts: Reciprocity, Asymmetry, and Detachment.

Using qualitative data collected from adolescent Latinas and their parents, this article describes ways in which family relationships are organized within low-income Latino families (n = 24) with and without a daughter who attempted suicide. Based on a family-level analysis approach, we present a framework that categorizes relationships as reciprocal, asymmetrical, or detached. Clear differences are identified: Families of non-attempters primarily cluster in reciprocal families, whereas families with an adolescent suicide attempter exhibit characteristics of asymmetrical or detached families. Our results highlight the need for detailed clinical attention to family communication patterns, especially in Latino families. Clinicians may reduce the likelihood of an attempt or repeated attempts by raising mutual, reciprocal exchanges of words and support between parents and daughter.