Humanistic education in surgery: a "patient as teacher" program for surgical clerkship.

Summary: Surgeons are frequently perceived by medical students to be uncompassionate, resolute and individualistic. Surgical education often prioritizes teaching and learning approaches that perpetuate these perceptions. In other specialties, engaging patients in education has shown promise in refocusing attention from the technical and procedural aspects of care toward the humanistic and social aspects. Despite proven favourable outcomes for both patients and students in many clinical areas, a "patient as teacher" approach to surgical education has yet to be adopted widely in Canada. A patient as teacher program was developed for surgical clerks at the University of Toronto with the goal of emphasizing the humanity of the patient, the psychosocial impact of a surgical diagnosis of breast cancer on patients and their families, and the social and humanistic roles for surgeons in providing patient-centred care. We report on the program's development process and pilot session.

Patient involvement in health professionals' education: a meta-narrative review.

More than 100 years ago, Osler inspired educators to consider health professions education (HPE) as intricately reliant on patients. Since that time, patient involvement in HPE has taken on many different meanings. The result is a disparate body of literature that is challenging to search, making it difficult to determine how to continue to build knowledge in the field. To address this problem, we conducted a review of the literature on patient involvement in HPE using a meta-narrative approach. The aim of the review was to synthesize how questions of patient involvement in HPE have been considered across various research traditions and over time. In this paper, we focus on three scholarly communities concerned with various interpretations of patient involvement in HPE-patient as teachers, real patients as standardized patients, and bedside learning. Focus on these three research communities served as a way to draw out various meta-narratives in which patients are thought of in particular ways, specific rationales for involvement are offered, and different research traditions are put to use in the field. Attending to the intersections between these meta-narratives, we focus on the potentially incommensurate ways in which "active" patient engagement is considered within the broader field and the possible implications. We end by reflecting on these tensions and what they might mean for the future of patient involvement, specifically patient involvement as part of future iterations of competency based education.

Persistent influence of a narrative educational program on physician attitudes regarding patient care.

PURPOSE: Educational approaches involving patient stories aim at enhancing empathy and patient-centered care; however, it is not known whether the influence of such programs on physician attitudes persists beyond medical school. MATERIALS AND METHODS: The Family Centered Experience (FCE) paired preclinical medical students with patient families over two years and engaged students in reflective dialogs about the volunteers' stories. This study examined possible long-term influences on attitudes toward medicine and doctoring. Interviews were conducted with former students at the end of or after post-graduate training. All had completed the FCE between 4 and 10 years before the study. Thematic analysis was informed by a constructivist Grounded Theory approach. RESULTS: Several themes were identified. The FCE made graduates aware of the patients' perspectives and impacted their clinical practice in specific ways, such as developing collaborative partnerships, conducting family meetings, and breaking bad news. The course had influenced career choices and interest in teaching. Finally, the FCE enhanced appreciation of the human dimensions of medicine, which graduates had drawn upon in subsequent years. CONCLUSIONS: A program based on longitudinal interactions with individuals with chronic illness can have persistent influence by stimulating reflection on the patient's perspective and humanistic approaches to patient care.

Creative art and medical student development: a qualitative study.

OBJECTIVES: Although many medical schools include arts-based activities in their curricula, empirical evidence is lacking regarding how the creation of art might impact medical students and their professional development. We used a qualitative research design in order to understand this process. METHODS: We conducted and analysed interviews with 16 medical students who had created and presented original artwork in the context of a required narrative-based undergraduate medical education programme. Teams of students collaborated to create interpretive projects based on common themes arising from conversations with individuals with chronic illness and their families. Open-ended questions were utilised to explore the conceptualisation and presentation of the projects, the dynamics of teamwork and the meaning(s) they might have for the students' professional development. We identified themes using repeated contextual reading of the transcripts, which also enhanced accuracy of the interpretations and ensured saturation of themes. RESULTS: Several major themes and sub-themes were identified. The creation of art led to a sense of personal growth and development, including reflection on past life experiences, self-discovery and an awareness of art as a creative outlet. Students also reported an enhanced sense of community and the development of skills in collaboration. Lastly, students reflected on the human dimensions of illness and medical care and identified an enhanced awareness of the experience of those with illness. CONCLUSIONS: A programme involving the creation of art based on stories of illness encouraged students' explorations of conceptions of the self, family and society, as well as illness and medical care, while enhancing the development of a collaborative and patient-centred worldview. Creative art can be a novel educational tool to promote a reflective, humanistic medical practice.

Use of interactive theater and role play to develop medical students' skills in breaking bad news.

Creative arts have been increasingly implemented in medical education. This study investigated the use of interactive theater and role play with professional actors in teaching breaking bad news to medical students. The objectives were to explore the contexts, approaches, experiences, and reactions in giving and receiving bad news. Second-year medical students participated in a required educational session that utilized interactive theater which helps students learn about the issues of breaking bad news to a patient with cancer. Following the interactive theater piece, professional actors provided students role play experiences in small groups with breaking bad news. Anonymous evaluation surveys were given out to all second-year medical students at the conclusion of the breaking bad news session. Surveys contained quantitative and qualitative responses. Three years of evaluations were analyzed. A total of 451 (88 %) students completed the evaluations. Comments were thematically analyzed. Ninety-four percent agreed that the theater piece prompted reflection on patient-provider communications, and 89 % agreed that it stimulated discussion on complex issues with breaking bad news. The two most common themes in student comments concerned the importance of realism in the theater piece, and the value of experiencing multiple perspectives. Use of professional actors during the role play exercises enhances the realism and pushed the students out of their own "comfort zones" in ways that may more closely approximate real life clinical situations. Interactive theater can be a potentially powerful tool to teach breaking bad news during medical school.

On the way to reflection: a conversation on a country path.

Ways of exploring the related acts of thinking and reflection are not just confined to expository prose. Following Heidegger's (1966) model of a conversation that gradually reveals deeper meanings of the concept of thinking, the following is a record of a conversation during a walk in the country on a summer's evening. Three individuals, a Doctor, a Philosopher, and a Poet, revisit the topic of reflection from a variety of different perspectives in hopes of understanding its place in the practice of medicine. In particular, they explore an area of reflection where medicine is often silent: during times of great suffering and loss. Along this country path, as night gradually falls, they attempt to capture the complex meanings of reflection that culminate in that intimate "open space" where medicine is practiced and where fundamentally important human events occur.

From skillful to empathic: evaluating shifts in medical students' perceptions of surgeons through a combined patient as teacher and arts-based reflection program.

Introduction: The purpose of this study was to identify whether the incorporation of a combined Patient as teacher (PAT) and arts-based reflection (ABR) program during a surgical clerkship rotation could influence more humanistic perceptions of surgeons, using an innovative evaluation approach. Methods: A novel, single question evaluation tool was created. Third year medical-students were asked to "list the top 5 attributes of a surgeon, in order of perceived importance" both before and after their surgical clerkship rotations and participation in the PAT/ABR program. Attributes identified by students were coded as either "humanistic" or "non-humanistic," which were then analyzed using generalized linear regression models under a Bayesian framework. Results: After participation in the PAT/ABR program, the predicted probability of students ranking a humanistic characteristic as the most important attribute of a surgeon had increased by 17%, and the predicted probability of students ranking a humanistic characteristic amongst their top three attributes for a surgeon had increased by 21%. Conclusion: This innovative evaluative method suggested the success of a combined PAT/ABR program in encouraging a humanistic perspective of surgery and this approach could potentially be explored to evaluate other humanistic education initiatives.

Introduction: L'objectif de cette étude était de déterminer si l'introduction d'une nouvelle approche d'évaluation associant la participation de Patients comme enseignants (PCE) à une Réflexion basée sur les arts (RBA) dans un stage d'externat en chirurgie permettait de mieux percevoir les qualités humanistes chez les chirurgiens. Méthodes: Un nouvel outil d'évaluation à question unique a été créé. Des étudiants en troisième année de médecine ont été invités à ''énumérer les cinq principaux attributs d'un chirurgien, par ordre d'importance perçue'', avant et après leur stage d'externat en chirurgie et le programme PCE/RBA. Les attributs identifiés par les étudiants ont été codés comme « humanistes ¼ ou « non humanistes ¼, puis analysés à l'aide de modèles de régression linéaire généralisée dans un cadre bayésien. Résultats: Après leur participation au programme PCE/RBA, la probabilité prédite moyenne que les étudiants classent un trait humaniste comme l'attribut le plus important d'un chirurgien a augmenté de 17 %, et la probabilité prédite que les étudiants classent un trait humaniste parmi les trois premiers attributs d'un chirurgien a augmenté de 21 %. Conclusion: Cette méthode d'évaluation innovante porte à croire que le programme PCE/RBA réussit en effet à favoriser une vision humaniste de la chirurgie. Cette approche peut être explorée pour évaluer d'autres activités de formation axées sur l'humanisme.

Discomfort, Doubt, and the Edge of Learning.

Discomfort is a constant presence in the practice of medicine and an oft-ignored feature of medical education. Nonetheless, if approached with thoughtfulness, patience, and understanding, discomfort may play a critical role in the education of physicians who practice with excellence, compassion, and justice. Taking Plato's notion of aporia-a moment of discomfort, perplexity, or impasse-as a starting point, the author follows the meandering path of aporia through Western philosophy and educational theory to argue for the importance of discomfort in opening up and orienting perspectives toward just and humanistic practice. Practical applications of this approach include problem-posing questions (from the work of Brazilian education theorist Paulo Freire), exercises to "make strange" beliefs and assumptions that are taken for granted, and the use of stories-especially stories without endings-all of which may prompt reflection and dialogical exchange. Framing this type of teaching and learning in Russian psychologist L.S. Vygotsky's theories of development, the author proposes that mentorship and dialogical interactions may help learners to navigate through moments of discomfort and uncertainty and extend the edge of learning. This approach may give birth to a zone of proximal development that is enriched with explorations of self, others, and the world.

The Powers of a Fish: Clinical Thinking, Humanistic Thinking, and Different Ways of Knowing.

How are ways of knowing similar between clinical reasoning and the humanities, and can the latter be used to elucidate the former? This commentary considers a conceptual model proposed by Prince and colleagues in this issue to explore the different ways of knowing in art and medicine. Their proposed model links 2 approaches to clinical reasoning with an analytic approach said to be characteristic of the humanities-visual thinking strategies (VTS)-to teach skills in clinical reasoning. They suggest that the VTS approach aligns well with the 2 clinical reasoning approaches and use this relationship to argue for the introduction of the humanities into graduate medical education. However, is VTS truly an exemplar of analytic approaches used in the humanities? The approach to clinical decision making is a version of what Donald A. Schön calls technical rationality, but what is the epistemology used in the humanities and art? This commentary explores this question through the perspective of hermeneutics, a branch of philosophy that centers on an interpretive understanding of art, and through art, a way of knowing the self, others, and the world. In contrast to limiting the focus of the humanities in medical education to sharpening the powers of observation and analytical thinking, the author argues that art also offers a way to explore the challenges and triumphs of providing care to those in need and to explore the meanings, feelings, and experiences of living and dying. It offers a way of understanding and expressing the moral dilemmas of our time that aspires toward the aesthetic, philosophical, and existential truths of a life in medicine.

Examining the Impact of Dialogic Learning on Critically Reflective Practice.

PURPOSE: While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies. METHOD: In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective. RESULTS: The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences. CONCLUSIONS: The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

Stories in the Time of COVID-19.

The time of COVID-19 is the time of storytelling-stories of chaos, loss, and despair, but also of victories large and small, acts of kindness, and deep connections. Stories are a way to pass on meaning from one person to another, among communities, and across generations. COVID-19 stories are being used in the education of physicians, but for whose benefit and to what end? What if the "heroic" frontline worker is experiencing burnout or working out of necessity rather than by choice? What if the battle against an invisible enemy does not end triumphantly but becomes an interminable war of attrition? It is important not only to propose new questions but also to create spaces for stories that do not fit conveniently into standard narratives. Stories help foster the energy and drive to write about what is next and to act as physicians in the service of human beings and their lives.

Professionalism revisited during the pandemics of our time: COVID-19 and racism.

In this article the authors review the current-day definition of professionalism through the lens of the two ongoing pandemics: COVID-19 and racism. The pandemics have led to contemporary practice-related questions, such as: does professionalism entail that health care providers (HCP) be compelled to treat patients without PPE or if patients refuse to wear masks? And what role do HCP play in society when confronted with glaring health disparities and police brutality? The authors propose using care ethics as a theory to view professionalism, as it takes into account broadly encompassing relationships between HCP and society, history and context. Professionalism viewed through a care ethics lens would require professionalism definitions to be expanded to allow for interventions, i.e., not just refrain from doing harm but actively interfere or take action if wrong is being witnessed. Principles related to the primacy of patient welfare need to be re-addressed to prevent systematic self-sacrifice which results in harm to HCP and burnout. Mature care should be a characteristic of professionalism ensuring that HCP care for the sick but be practically wise, highlighting the importance of balancing too little and too much care for self and others. Professionalism needs to be viewed as a bi-directional relational exchange, with society demonstrating solidarity with those providing care. Additionally, given the scale of health disparities, simply stating that HCP need to work towards social justice oversimplifies the problem. Professionalism needs to encompass incorporating critical action and critical pedagogy into health care training and the health care profession to demonstrate solidarity with those impacted by racism.

Paradox of Patient-Centered Care and the Implications for Patient Involvement in Continuing Professional Development.

INTRODUCTION: Patient-centered care (PCC) is widely considered as essential in chronic disease management. As the underlying rationale for engaging patients in continuing professional development (CPD) is commonly described as fostering care that is more patient-centered, we hoped to understand the discursive conditions for how educators and health professionals can (or cannot) learn with, from, and about patients. METHODS: Using diabetes as a case, we conducted a Foucauldian discourse analysis of an archive of relevant policy documents, professional and educational texts, to explore different conceptualizations of practice and the implications for PCC. We also conducted in-depth interviews with a purposive sample of physicians to understand their experiences in providing and teaching PCC. We sought to understand: How has PCC been discursively constructed? Whose interests does advocating PCC serve? What are the implications for patient involvement in CPD? RESULTS: We describe three discursive constructions of PCC, each extending the reach of biomedical power. PCC as a disease intervention emphasizes knowing and relating to patients to normalize laboratory test results. PCC as a form of confession promotes patients to come to their own realizations to become responsible for their own health, but through the lens and evaluation of physicians. PCC as a disciplinary technique makes visible the possibility of using a checklist to judge physician competency in providing PCC. DISCUSSION: PCC may be constructed in ways that paradoxically reinforce rather than challenge conventional, provider-centric paradigms. Our results challenge educators to acknowledge the existence and effects of discourses when involving patients in the planning and delivery of CPD.

Coming of age with sickle cell disease and the role of patient as teacher.

OBJECTIVE: Patients with chronic conditions are encouraged to optimize their health care experience by educating themselves regarding their condition and care. This study sought to explore the ways in which adolescents and young adults with sickle cell disease (SCD) educate others about their condition and the meanings they give to their experiences with health care professionals. METHODS: Seventeen individuals with SCD participated in in-depth interviews regarding their experiences as an individual with SCD seeking health care. RESULTS: Our analysis revealed participants' belief in the ignorance concerning SCD by others, including health care professionals. Additionally, the participants suggested significant consequences of such a lack of knowledge and the strategies they used to overcome this barrier--primarily the development of the identity of patient-as-teacher. CONCLUSION: Sickle cell patients in general and adolescent sickle cell patients in particular are often underestimated and discounted as they relate the details of their pain. This study demonstrates that these participants are not only keepers of knowledge but also must work to educate authority figures and peers in their lives to ensure they are properly cared for and that those around them understand their disease.

On Time and Tea Bags: Chronos, Kairos, and Teaching for Humanistic Practice.

In these days of overwhelming clinical work, decreased resources, and increased educational demands, time has become a priceless commodity. Competency-based medical education attempts to address this challenge by increasing educational efficiency and decreasing the "steeping" of learners in clinical activities for set durations of time. However, in this environment, how does one teach for compassionate, humanistic practice? The answer arguably lies in clinician-teachers' recognition and engagement in a different type of time, that of kairos. Ancient Greek thought held that there were 2 interrelated types of time: chronological, linear, quantitative time-chronos-and qualitative, opportune time-kairos. Unlike chronos, kairos involves a sense of the "right time," the "critical moment," the proportionate amount. Developing a sense of kairos involves learning to apply general principles to unique situations lacking certainty and acting proportionally to need and context. Educationally, it implies intervening at the critical moment-the moment in which a thoughtful question, comment, or personal expression of perplexity, awe, or wonder can trigger reflection, dialogue, and an opening up of perspectives on the human dimensions of illness and medical care. A sensibility to kairos involves an awareness of what makes a moment "teachable," an understanding of chance, opportunity, and potential for transformation. Above all, inviting kairos means grasping an opportunity to immerse oneself and one's learners-even momentarily-into an exploration of patients and their stories, perspectives, challenges, and lives.

Diabetes stories: use of patient narratives of diabetes to teach patient-centered care.

A critical component to instituting compassionate, patient-centered diabetes care is the training of health care providers. Our institution developed the Family Centered Experience (FCE), a comprehensive 2-year preclinical program based on longitudinal conversations with patients about living with chronic illness. The goal of the FCE is to explore the experience of illness from the patient's perspective and ultimately to incorporate this perspective in clinical practice. In this qualitative study, we wished to investigate the impact of "diabetes stories"--the stories of FCE volunteers with diabetes--on medical students' understanding of diabetes and its management. Individual interviews were conducted with medical students who had worked with a volunteer with diabetes to answer the questions: "in what ways was learning through these 'diabetes stories' different from that acquired through lectures and textbooks," and "how did these stories impact the students' understanding of diabetes and its care?" Thematic analysis of the transcribed interviews was performed using Grounded Theory. Several major themes emerged: There was more to diabetes than the "scientific" knowledge acquired through lectures; the stories challenged students' assumptions about having or working with people with diabetes and allowed students to see the world through the perspective of someone with diabetes, and the stories motivated students' development as physicians and influenced their general perspectives of doctoring and medicine. First-person narratives of living with diabetes allow for learning in affective, experiential, and cognitive dimensions, stimulate self reflection and perspective-taking, and enhance growth through the challenging of previous assumptions, beliefs, and perspectives. This type of learning is transformative and may result in a shift in students' perspectives towards more open, inclusive attitudes towards patient-centered diabetes care.

A Matter of Trust.

Trust is a fundamental tenet of the patient-physician relationship and is central to providing person-centered care. Because trust is profoundly relational and social, building trust requires navigation around issues of power, perceptions of competence, and the pervasive influence of unconscious bias-processes that are inherently complex and challenging for learners, even under the best of circumstances. The authors examine several of these challenges related to building trust in the patient-physician relationship. They also explore trust in the student-teacher relationship. In an era of competency-based medical education, a learner has the additional duty to be perceived as "entrustable" to 2 parties: the patient and the preceptor. Dialogue, a relational form of communication, can provide a framework for the development of trust. By engaging people as individuals in understanding each other's perspectives, values, and goals, dialogue ultimately strengthens the patient-physician relationship. In promoting a sense of agency in the learner, dialogue also strengthens the student-teacher relationship by fostering trust in oneself through development of a voice of one's own.

A Dialogic Approach to Teaching Person-Centered Care in Graduate Medical Education.

BACKGROUND: Training future physicians to provide compassionate, equitable, person-centered care remains a challenge for medical educators. Dialogues offer an opportunity to extend person-centered education into clinical care. In contrast to discussions, dialogues encourage the sharing of authority, expertise, and perspectives to promote new ways of understanding oneself and the world. The best methods for implementing dialogic teaching in graduate medical education have not been identified. OBJECTIVE: We developed and implemented a co-constructed faculty development program to promote dialogic teaching and learning in graduate medical education. METHODS: Beginning in April 2017, we co-constructed, with a pilot working group (PWG) of physician teachers, ways to prepare for and implement dialogic teaching in clinical settings. We kept detailed implementation notes and interviewed PWG members. Data were iteratively co-analyzed using a qualitative description approach within a constructivist paradigm. Ongoing analysis informed iterative changes to the faculty development program and dialogic education model. Patient and learner advisers provided practical guidance. RESULTS: The concepts and practice of dialogic teaching resonated with PWG members. However, they indicated that dialogic teaching was easier to learn about than to implement, citing insufficient time, lack of space, and other structural issues as barriers. Patient and learner advisers provided insights that deepened design, implementation, and eventual evaluation of the education model by sharing experiences related to person-centered care. CONCLUSIONS: While PWG members found that the faculty development program supported the implementation of dialogic teaching, successfully enabling this approach requires expertise, willingness, and support to teach knowledge and skills not traditionally included in medical curricula.