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INTRODUCTION: To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. METHODS: We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. RESULTS: We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. CONCLUSION: This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.
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Medical-school applicants learn from many sources that they must stand out to fit in. Many construct self-presentations intended to appeal to medical-school admissions committees from the raw materials of work and volunteer experiences, in order to demonstrate that they will succeed in a demanding profession to which access is tightly controlled. Borrowing from the field of architecture the lens of construction ecology, which considers buildings in relation to the global effects of the resources required for their construction, we reframe medical-school admissions as a social phenomenon that has far-reaching harmful unintended consequences, not just for medicine but for the broader world. Illustrating with discussion of three common pathways to experiences that applicants widely believe will help them gain admission, we describe how the construction ecology of medical school admissions can recast privilege as merit, reinforce colonizing narratives, and lead to exploitation of people who are already disadvantaged.
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Critérios de Admissão Escolar , Faculdades de Medicina , HumanosRESUMO
In this article, we address the question, 'What is the role of autonomy in physician development?' Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self-determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self-regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with 'hands-on' approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.
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Educação Médica , Médicos , Humanos , Aprendizagem , Motivação , Autonomia Pessoal , Teoria PsicológicaRESUMO
PhenomenonNear-peer interactions (NPIs) provide formal and informal mentorship that can allow medical students to share strategies for successful training. Such capacity to convey valuable advice, however, may depend on the similitude of experiences. Given that many factors can disrupt homogeneity, including curriculum renewal, we must better understand whether junior trainees feel disadvantaged when they do not have more senior peers with similar experiences. This study was, therefore, conducted to examine the focus of, and engagement with, advice available through NPIs during curriculum renewal. Approach: We used a generic exploratory qualitative research approach. Twenty MD undergraduate students, seven from the Class of 2019 (the first cohort post-curriculum change), and thirteen from the Class of 2020 (the first cohort with access to more senior students in the new curriculum), participated in semi-structured interviews. Anonymized transcriptions were analyzed with open, axial, and selective coding to generate themes until saturation was attained. Findings: Participants from the Class of 2019 reported having particularly few reasons to seek advice; because curriculum renewal disrupted their near peers' capacity to provide critical insights, students exerted little effort to learn from them. That said, this vacuum was not generally cause for concern. Deeper probing illustrated why: advice given during NPIs in both classes more commonly focused on nonacademic (e.g., work-life balance issues) than academic advice; academic advice, when sought or offered, tended not to be aimed at improving understanding of curriculum dependent content; and, while students in both classes welcomed advice, both were wary of accepting it at face value, precluding a sense of dependence on senior peers. Insights: Students' skepticism about the overall utility of academic advice raises a number of important issues for medical education and training. Positively, it shielded students from feeling loss when advice from similarly trained students was not available, reducing concerns about disadvantage that could arise during periods of curriculum revision. On the other hand, knowing that what students perceive and what educators claim to be important aspects of training can be at odds and knowing that self-assessment is flawed makes it surprising and unsettling, respectively, that participants so readily treated the lessons learned by those who came before them as irrelevant.
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Educação de Graduação em Medicina , Educação Médica , Estudantes de Medicina , Currículo , Humanos , Mentores , Grupo AssociadoRESUMO
INTRODUCTION: Medical education is moving to conceptualise feedback as a bidirectional learning conversation. Within this conversation, learners experience a tension between assessment and feedback. That perceived tension affects learners' outward performances. In this study, we aimed to characterise residents' experiences with this tension and its effect on learner authenticity within feedback conversations. METHODS: In this constructivist grounded theory study, the authors were informed by Goffman's theory of impression management. During data analysis, Dweck's theory of mindset was adopted. The authors conducted semi-structured interviews with 15 internal medicine residents. Data collection and analysis were conducted iteratively, using constant comparison to identify themes coinciding with impression management and mindset, ultimately developing a theoretical model to help explain residents' responses to tensions within feedback conversations. RESULTS: Residents constantly felt 'scrutinized', and this affected their engagement in feedback conversations. They staged a performance within those conversations, linked to their underlying mindset: growth or fixed. Growth mindset was characterised by a focus on development as a physician and was associated with asking questions and seeking opportunities for growth. Fixed mindset was characterised by a focus on achieving a favourable evaluation and was associated with a hesitation to ask questions when faced with uncertainty and admit opportunities for growth, because they were concerned about impression management. Context influenced mindset and impression management. Residents adopted a fixed mindset and managed impressions when they perceived the permanence or consequences of evaluations within feedback. Residents adopted a growth mindset when they trusted the supervisor. DISCUSSION: Residents assess the context of feedback conversations, altering the authenticity of their behaviours. Context, including the perceptions of formal assessment and relationships with supervisors, affected residents' mindset and impression management. Providing space for relationship-building and clarifying the purpose and structure of assessment may be helpful in supporting effective learning conversations in graduate medical education.
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Internato e Residência , Comunicação , Educação de Pós-Graduação em Medicina , Retroalimentação , Humanos , Pesquisa QualitativaRESUMO
CONTEXT: Myth busting engages scholars in the critical examination of commonly accepted but poorly evidenced claims with the goal of instilling quality and trust in knowledge making. The debunking of such knowledge "myths" and associated misguided practices purportedly serves to avert resources and attention from wasteful and dangerous scholarship. We address the myth that "all myths in medical education deserve to be busted". METHODS: Using a critical narrative approach, we searched the medical education literature for orientations to myths and myth busting, and reviewed this literature analytically drawing from the sociology of science and Merton's concepts of manifest and latent functions. The results of this analysis are presented in the form of a narrative that deploys the articles reviewed to explore the utility of myth busting for medical education reform and begins with a brief exploration of the etymology of "myth" and how meaning making is related to symbols, practices and storytelling. RESULTS: Our analysis revealed the important function of myths in the social practice of medical education and practice. A deconstruction of five salient examples of the contemporary myth in medical education (the myth of the "ideal candidate", the myth of "cut-throats", the myth of "cadaver stories", the myth of "learning styles", and the myth of "patient information leaflets") demonstrates that myths continue to have material effects even after they have been busted. CONCLUSIONS: Our analysis makes evident that myth busting disrupts, renegotiates and reconstitutes socio-epistemic relationships rather than simply correcting falsehoods. We also argue that myths play important and inescapable roles in the social practice of medical education and the negotiation of values, and in constructing the conditions for group change and transformation. Imperatives related to humanism, compassion and patient engagement offer a healthy humanising counter-mythologising that we suggest must survive any contemporary myth-busting endeavour aimed at improving medical education practice.
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Medicina Baseada em Evidências , Conhecimento , Mitologia , Narração , Educação Médica , HumanosRESUMO
CONTEXT: Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training. METHODS: Using constructivist grounded theory, we conducted 23 semi-structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de-identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data. RESULTS: Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making 'real decisions' for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care. CONCLUSIONS: This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.
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Educação Médica , Internato e Residência , Competência Clínica , Humanos , Autonomia Profissional , Pesquisa Qualitativa , Identificação SocialRESUMO
Longitudinal Integrated Clerkships (LICs) have a growing presence as a model of educational delivery on the stage of UK medical education, where they are most frequently based within primary care. Yet, despite both local and internationally reported benefits, significant challenges to programme implementation and student engagement remain. Although perhaps initially challenges could be explained by the novelty of LICs, UK LICs have aged, yet challenges remain, leading to the marginalisation of LICs within UK medical schools. This leading article suggests institutional hidden curricula may be an important vehicle for this marginalisation and explores how the dominant fact-based paradigm of UK medical education could act to dissuade student engagement with LICs. So long as the hidden curricula messages we transmit to early-stage medical students revolve around the disproportionate importance of cognitive knowledge acquisition, UK-based LICs are unlikely to realise their full impact or benefit, in comparison to successfully running LICs internationally. Alternatively, refocusing early medical education on patient interaction, encouraging students to take an active role in their care, would send a different hidden curricula message more aligned with the ethos of LICs, and so would likely increase uptake to later stage comprehensive programmes.
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Estágio Clínico , Educação Médica/métodos , Atenção Primária à Saúde , Estudantes de Medicina/psicologia , Atitude do Pessoal de Saúde , Humanos , Reino UnidoRESUMO
Within the fields of medicine and sociology, the descriptor "profession" (along with its brethren: profession, professionalization, and professionalism) has had a rich etymological history, with terms taking on different meanings at different times-sometimes trespassing into shibboleth and jargon. This etymological journey has co-evolved with the career of David Mechanic to whom this issue of the Journal of Health Politics, Policy and Law is devoted. We exploit a provocative metaphor applied to Mechanic's work on the challenges facing medicine as a profession as a playful exegesis on what we call "profession" to excavate an ensconced and encrusted domain of health jargon operating at the tensive interface of society and modern medical work.
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Medicina , Política , Sociologia , Humanos , MetáforaRESUMO
ABSTRACT: Over the past decade, entrustable professional activities (EPAs) have become an important element in the competency-based medical education movement. In this Commentary, the authors explore informed consent as an EPA within resident surgical training. In doing so, they foreground the concept of culture and reexamine the nature of trust and entrustment decisions from within a cultural framework. The authors identify role modeling and professional identity formation as core elements in the training process and suggest that faculty are sometimes better off using these tools than uncritically adopting a formal EPA framework for what is, in essence, a professionally oriented and values-based moral enterprise. They conclude that EPAs work best when they are developed at a local level, stressing the unique culture of specialty and program as well as the care that must be taken when attempting to transfer notions of entrustment from the undergraduate medical education level to graduate medical education settings.
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Educação Baseada em Competências , Consentimento Livre e Esclarecido , Internato e Residência , Humanos , Consentimento Livre e Esclarecido/ética , Educação Baseada em Competências/métodos , Cirurgia Geral/educação , Competência Clínica , Confiança , Educação de Pós-Graduação em Medicina/métodosRESUMO
Physician organizations, academic institutions and accrediting bodies agree that professionalism is important to medicine. A number of them have created codes of conduct and competencies related to professionalism. Yet studies have shown that physicians face challenges as they seek to put the principles of professionalism into practice. This article examines four realities of medicine today-the potential for conflicts of interest, the advent of social media, the lack of professionalism education beyond medical school and residency, and the lack of support from organizations for which physicians work-that challenge medical professionalism.
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Competência Clínica/normas , Códigos de Ética , Ética Médica/educação , Papel do Médico , Conflito de Interesses , Educação Médica/ética , Humanos , Internato e Residência/ética , Minnesota , Cultura Organizacional , Mídias Sociais/éticaRESUMO
The college-level pathway to medical school (i.e., the "premed path") includes all coursework, extra-curriculars, shadowing, volunteering, high-stakes examination (e.g., MCAT®), and application-related processes. Although medical school admission committees routinely insist their interest in diverse and "well-rounded" applicants, the premed path (PMP), through formal and informal mechanisms, is constructed to favor those from high in socioeconomic status (SES) privileged backgrounds, and those majoring in typical premed majors such as in the Biological Sciences. In these respects, the PMP is an example of Discriminatory Design-an entity constructed and sustained in a manner that (un)intentionally discriminates against certain groups of individuals. We begin this paper by providing a brief description of the PMP (within the U.S. specifically) and conceptual and theoretical overview of the discriminatory design framework. We then explore how the PMP is an example of discriminatory design through the distinct but related role(s) of financial, social, cultural, and (what we term) (extra)curricular capital. Using data gleaned from interviews with premedical students, content analyses of the curricular structure of particular majors and publicly available data on the various "costs" associated with the PMP, we detail how the PMP is reflective of discriminatory design, spotlighting specific barriers and hurdles for certain groups of students. Given the persistent lack of representation of students from minoritized groups as well as those from diverse academic backgrounds within medical schools, our goal is to spotlight key features and processes within the PMP that actively favor the pursuit of certain majors and students from more privileged backgrounds. In turn, we conclude by offering medical schools and undergraduate institutions specific recommendations for remediating these barriers and hurdles.
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Despite recent attention to social justice, diversity, equity, and inclusion within medical education, little is currently known about whether and to what extent that attention has translated into the language of formal documents articulating organization purpose: medical school mission statements. Mission statements are the marquee declaration of a medical school's identity and purpose, and a recommended tool for applicants to determine "fit" when applying. This study examines whether and to what extent social justice, diversity, equity, and inclusion have made it into the formal public statements of organizational purpose and identity over the last several years. Mission statements were extracted manually from the 2007, 2017, and 2021 AAMCs Medical School Admission Requirements (MSAR) database for both U.S. and Canadian M.D. granting medical schools. Then each mission statement version was coded for the presence and degree of diversity language including words like social justice, diversity, equity, and inclusion using an agreed-upon lexicon. Frequencies and within school changes over time were analyzed. Among 139 medical schools with discoverable mission statements from 2007, 91% (n=127) changed their MSs between 2007 and 2021. In 2007, 24% (n=33) of MSs contained diversity language. By 2017 nearly half of MSs; 47% (n=65) contained any reference to such language. But by 2021, despite 46 school having changed their MSs again, only a few more included diversity language in their MSs (56%; n=77). The most common terms used were "diversity," followed by the increasing presence of words like "inclusion," "equity," and "justice" by 2021. Curiously, a few schools redacted diversity language from 2007 to 2021. A Diversity Thesaurus of 22 terms was iteratively identified, with all terms searched in all MSs. Overall, mission statement change was quite common with most medical schools making changes across the 14 years covered in this study. And despite a doubling of the number of medical schools MSs mentioning diversity over a 10-year period, that increase seemed to slow in recent years even among schools who had a chance to change their MS. As of mid-2021, two in five US medical schools still have no mention of diversity related language in their most formal, said articulation of organizational purpose.
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Educação Médica , Faculdades de Medicina , Humanos , Objetivos Organizacionais , Canadá , IdiomaRESUMO
Impostor phenomenon has gained increasing attention within the health care and health professions education literature. Although consistently depicted as a debilitating socioemotional experience, studies also suggest a strategic aspect to impostor phenomenon - denoting a conceptual ambiguity to impostor phenomenon that has yet to fully examined. Within this paper, we use humility as a conceptual sparring partner with impostor phenomenon to examine the similarities and differences between the concepts, as well as explore the various nuances associated with impostor phenomenon. By comparing and contrasting impostor phenomenon and humility from interdisciplinary perspectives and within the context of health professions specifically, we not only further refine their meaning and usage within the literature, but also spotlight key areas for future research.
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Transtornos de Ansiedade , Autoimagem , HumanosRESUMO
PURPOSE: Professional identity formation (PIF) is a dynamic process by which an individual internalizes the core values and beliefs of a specific profession. Within medical education, PIF begins in medical school and continues throughout training and practice. Transitions affect PIF, with a critical transition occurring between medical training and unsupervised practice. This study aims to characterize PIF during the transition from resident to early-career faculty physician and explores the relationship between PIF and burnout during this transition. METHOD: The authors conducted a qualitative study using constructivist grounded theory. They conducted semistructured interviews with early-career faculty physicians (defined as practicing for ≤ 5 years) from the Department of Medicine, Mayo Clinic. Deidentified interview transcripts were processed through open and axial coding. The authors organized themes and identified relationships between themes that were refined through discussion and constant comparison with newly collected data. During data analysis, the authors identified self-determination theory, with the concepts of autonomy, competence, and relatedness, as a framework to support the organization and analysis of the data. RESULTS: Eleven early-career faculty physicians participated in the interviews. Their PIF was characterized by the dual desires to fit in and stand out. Striving for these desires was characterized by imposter syndrome, driving physicians to question their decision making and overall competence. Participants associated imposter syndrome and academic pressures with burnout. Autonomy support by the institution to pursue opportunities important for career development helped mitigate burnout and support PIF. CONCLUSIONS: Early-career faculty physicians face identity challenges when transitioning from training to unsupervised practice, including striving to fit in and stand out. They link this tension to imposter syndrome, which they associated with burnout. Institutional awareness and support, including addressing structural and cultural contributors to imposter syndrome, are paramount as new faculty explore their identities and navigate new challenges.