Becoming Doctors: Examining Student Narratives to Understand the Process of Professional Identity Formation Within a Learning Community.

BACKGROUND: Professional identity formation is a key aim of medical education, yet empiric data on how this forms are limited. METHODS: Our study is a qualitative analysis of student reflections written during the final session of our Becoming a Physician curriculum. After reading their medical school admission essay and their class oath, students wrote about a "time, or times during your third year when you felt like a doctor." The reflections were qualitatively analyzed by the evaluation team, looking for themes found in the reflections. RESULTS: Narrative themes separated into 4 distinct categories, specifically that performing physician tasks can make one feel like a doctor, demonstrating caring is a fundamental task of doctors, integrating personal ideals with professional values promotes professional identity formation, and the theme of never feeling like a doctor. Subsets of these broad categories provide further insight into individual and integrative tasks. Patients, patient families, and students through their own reflection prompted learners to feel like doctors in 74% of narratives, whereas physicians or the care team did so in 26% of our narratives. CONCLUSION: Students are able to reflect on times during their principal clinical year where they feel like doctors, taking a step toward forming a professional identity. Having faculty prompt and support such reflection can help faculty understand the student experience of their principal clinical year and promote professional identity formation.

Integrating Compassionate, Collaborative Care (the "Triple C") Into Health Professional Education to Advance the Triple Aim of Health Care.

Empathy and compassion provide an important foundation for effective collaboration in health care. Compassion (the recognition of and response to the distress and suffering of others) should be consistently offered by health care professionals to patients, families, staff, and one another. However, compassion without collaboration may result in uncoordinated care, while collaboration without compassion may result in technically correct but depersonalized care that fails to meet the unique emotional and psychosocial needs of all involved. Providing compassionate, collaborative care (CCC) is critical to achieving the "triple aim" of improving patients' health and experiences of care while reducing costs. Yet, values and skills related to CCC (or the "Triple C") are not routinely taught, modeled, and assessed across the continuum of learning and practice. To change this paradigm, an interprofessional group of experts recently recommended approaches and a framework for integrating CCC into health professional education and postgraduate training as well as clinical care. In this Perspective, the authors describe how the Triple C framework can be integrated and enhance existing competency standards to advance CCC across the learning and practice continuum. They also discuss strategies for partnering with patients and families to improve health professional education and health care design and delivery through quality improvement projects. They emphasize that compassion and collaboration are important sources of professional, patient, and family satisfaction as well as critical aspects of professionalism and person-centered, relationship-based high-quality care.

Back to the Future: What Learning Communities Offer to Medical Education.

Learning communities (LCs) have increasingly been incorporated into undergraduate medical education at a number of medical schools in the United States over the past decade. In an Association of Medical Colleges survey of 140 medical schools, 102 schools indicated that they had LC (described as colleges or mentorship groups; https://www.aamc.org/initiatives/cir/425510/19a.html). LCs share an overarching principle of establishing longitudinal relationships with students and faculty, but differ in the emphasis on specific components that may include curriculum delivery, advising/ mentoring, student wellness, and community. The creation of LCs requires institutional commitment to reorganize educational processes to become more student centered. LCs are beginning to show positive outcomes for students including benefits related to clinical skills development, advising, and student wellness, in addition to positive outcomes for LC faculty.

The role of relationships in the professional formation of physicians: case report and illustration of an elicitation technique.

OBJECTIVE: Studies of physicians' professional development highlight the important effect that the learning environment has in shaping student attitudes, behaviors, and values. The objective of this study was to better understand the interplay among relationships and experiences in mediating the effects of the learning environment. METHODS: We randomly recruited 2nd- and 4th-year students from among volunteers at each of five medical schools. One interviewer at each school conducted a face-to-face, open-ended, semi-structured interview with each student. The interviewers used a method called 'life-circle diagramming' to direct the student to draw a picture of all of the relationships in his/her life that had an influence on the sort of doctor that each student saw him/herself becoming. Interviews lasted between 60 and 120 min. Using a narrative framework that focuses on elements of students' stories (e.g., setting, characters, plot), we analyzed transcripts through an iterative process of individual reading and group discussion to derive themes and relationships among themes. RESULTS: Twenty students completed interviews. These students are embedded in complex webs of relationships with colleagues, friends, family, role models, patients, and others. Most students entered medical school with formed notions of what they wanted to 'be like' as physicians. While students generally gravitated toward relationships with like-minded people, their experiences varied, and some students could sense themselves changing as they moved through school. Such changes were often related to important events or issues. The relationships that students found themselves in during the context of these events had an important effect on students' beliefs about what kinds of behaviors and attitudes were possible and desirable in their future practice. CONCLUSIONS: Students proceed through medical school embedded in complex webs of relationships that exert a powerful influence (both positive and negative) on their formation as physicians. PRACTICE IMPLICATIONS: Educational interventions that foster adoption of professional values need to acknowledge the influence of relationships, and assist students to harness and shape relational effects on their growth and development. The life-circle diagramming activity holds potential to promote reflection and self-knowledge, and to provide a foundation for professional growth.

Teaching the medical interview: methods and key learning issues in a faculty development course.

OBJECTIVE: To describe the American Academy on Communication in Healthcare's (AACH) Faculty Development Course on Teaching the Medical Interview and report a single year's outcomes. DESIGN: We delivered a Faculty Development course on Teaching the Medical Interview whose theme was relationship-centered care to a national and international audience in 1999. Participants completed a retrospective pre-post assessment of their perceived confidence in performing interview, clinical, teaching, and self-awareness skills. PARTICIPANTS AND SETTING: A total of 79 participants in the 17th annual AACH national faculty development course at the University of Massachusetts Medical School in June 1999. INTERVENTION: A 5-day course utilized the principles of learner-centered learning to teach a national and international cohort of medical school faculty about teaching the medical interview. MEASUREMENTS AND MAIN RESULTS: The course fostered individualized, self-directed learning for participants, under the guidance of AACH faculty. Teaching methods included a plenary session, small groups, workshops, and project groups all designed to aid in the achievement of individual learning goals. Course outcomes of retrospective self-assessed confidence in interview, clinical, teaching, self-awareness, and control variables were measured using a 7-point Likert scale. Participants reported improved confidence in interview, clinical, teaching, and self-awareness variables. After controlling for desirability bias as measured by control variables, only teaching and self-awareness mean change scores were statistically significant (p < .001). CONCLUSIONS: The AACH Faculty Development course on Teaching the Medical Interview utilized learner-centered teaching methods important to insure learning with experienced course participants. Perceived teaching and self-awareness skills changed the most when compared to other skills.

Not the same everywhere. Patient-centered learning environments at nine medical schools.

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the "hidden curriculum." However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools. OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools. DESIGN: Cross-sectional internet-based survey. PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003. MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school's environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students' experiences, and support for students' patient-centered behaviors), and is designed to measure these areas independent of respondents' attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents. RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school. CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Challenges and opportunities for patients with HIV who educate health professionals.

BACKGROUND: Patient perspectives are valuable for clinical care and teaching. PURPOSE: To understand personal and programmatic effects of using HIV-infected persons as teachers in courses about care of HIV-infected people. METHODS: Semistructured interviews with HIV-infected faculty for New England AIDS Education and Training Center (NEAETC), addressing teaching decision and its personal, medical, and psychological consequences. Interview transcripts were analyzed via iterative, consensus building. RESULTS: Participants reported consequences of teaching that benefited them as patients (finding health care providers, increasing their knowledge base, and receiving tangible rewards such as gifts). A deeper level of benefit was realized personally, increasing control over their life and disease. Relationships, personal and professional, changed, from unilateral to mutual, heightening a sense of their own empowerment. Teaching built support networks and aided in coping with difficult issues raised (negative emotions, informing significant others about their infection, death and dying). Program support was essential for participation, allowing numerous teachers to transform teaching from individual messages to universal lessons. CONCLUSIONS: The program was well received and well regarded by participating teachers. Convenience sampling does not account for nonparticipating faculty viewpoints or those who left the program, but concrete benefits can be expected if support and investment by the program is in place. Learning by these HIV-infected teachers fits the characteristics of transformational learning.

Development and implementation of an objective structured teaching exercise (OSTE) to evaluate improvement in feedback skills following a faculty development workshop.

BACKGROUND: Faculty development programs focusing on teaching have become widespread. PURPOSE: Despite the popularity of such programs, evidence as to their effectiveness is limited. This article reports on the development of an objective structured teaching exercise (OSTE) and its pilot implementation in an evaluation of a faculty development program module. A written test intended to measure feedback skills was also developed and pilot tested. METHODS: A separate-sample, pretest-posttest design was used to pilot test both instruments. RESULTS: The results showed some evidence of significant differences between groups tested preworkshop and postworkshop. Higher scores were observed for the posttest group compared to the pretest group only for OSTE items focusing on prioritizing and limiting the amount of feedback given at one time and on action planning. CONCLUSIONS: Results suggest that an OSTE may be sensitive to changes in preceptor skill level for skills that are relatively easy to incorporate immediately into practice. Lack of differences in other skill areas may be due to lack of sensitivity of the measure or to need for practice and reflection before changes in performance on other feedback skills are evident.