Negotiating legitimacy and belonging: Disabled students' and practitioners' experience.

INTRODUCTION: People with disabilities are underrepresented in health professions education and practice. Barriers for inclusion include stigma, disabling discourses, discriminatory programme design and oppressive interactions. Current understandings of this topic remain descriptive and fragmented. Existing research often includes only one profession, excludes particular types of disability and focuses on one aspect of the career journey. To expand understanding, we examined the recurrent forms of social relations that underlie the participation of disabled individuals in learning and practice contexts across five health professions. METHOD: We analysed 124 interviews with 56 disabled health practitioners and students. Participants were interviewed up to three times over 1.5 years. Using constructivist grounded theory, authors used a staged analytic approach that resulted in higher level conceptual categories that advance interpretations of social processes. Finally, the authors compared and integrated findings among students and practitioners. RESULTS: Participants experience challenges to their sense of legitimacy and belonging as health providers. They describe tensions within the health education and practice between the commitment to inclusion and the day-to-day realities experienced by disabled participants. We identified six distinct, but related, conditions underlying these tensions: (i) validity and transparency of competencies' evaluation; (ii) the social and physical contexts; (iii) integration of inclusive practices; (iv) boundaries between personal and professional identities; (v) vulnerability to authority figures; and (vi) dynamic person-level factors. DISCUSSION: If we are to commit to health practitioners and students with disabilities experiencing an overall sense of legitimacy and belonging, priority needs to be given to system-level practices and policies to support inclusion. Attention to the day-to-day marginalisation of students and practitioners with disabilities in the health professions is also needed. Additionally, inclusive and transparent delineation of competency requirements is needed. Finally, educational actions are needed to increase understanding of disability in the health professions, with particular attention to promoting social relations that foster collective responsibility for supporting inclusion.

Social support experiences of students and clinicians with disabilities in health professions.

Social support is vital in promoting the health, well-being, and performance of students and clinicians in health professions. Health settings' demanding and competitive nature imposes unique challenges on students and clinicians with disabilities. This paper aims to explore the trajectories and experiences of social support interactions amongst students and clinicians with disabilities in health professions. In a qualitative longitudinal study, 124 in-depth semi-structured interviews were conducted with 27 health students and 29 health clinicians with disabilities. Data analysis was informed by grounded theory as an adapted analytic approach involving constant comparisons. A few main characteristics of social support and trajectories in which social support is negotiated emerged from the data: (1) The need to be accepted and not questioned when asking for support, (2) Support interactions that do not heighten otherness, (3) Failure to acknowledge the challenges, (4) Interactions that support the process of disclosure (5) Interactions that allow mobilization of social support without strain or an extra effort. These findings have important implications for designing more supportive health professions, educational programs, and workplaces for people living with disabilities.

Technical Difficulties: Teaching Critical Philosophical Orientations toward Technology.

Issue: Technological innovation is accelerating, creating less time to reflect on the impact new technologies will have on the medical profession. Modern technologies are becoming increasingly embedded in routine medical practice with far-reaching impacts on the patient-physician relationship and the very essence of the health professions. These impacts are often difficult to predict and can create unintended consequences for medical education. This article is driven by a main question: How do we prepare trainees to critically assess technologies that we cannot foresee and effectively use technology to support equitable and compassionate care? Evidence: We translate insights from the philosophy of technology into a proposal for integrating critical technical consciousness in medical curricula. We identify three areas required to develop critical consciousness with regard to emerging technologies. The first area is technical literacy, which involves not just knowing how to use technology, but also understanding its limitations and appropriate contexts for use. The second area is the ability to assess the social impact of technology. This practice requires understanding that while technification creates new possibilities it can also have adverse, unintended consequences. The third area is critical reflection on the relationship between 'the human' and 'the technical' as it relates to the values of the medical profession and professional identity formation. Human and technology are two sides of the same coin; therefore, thinking critically about technology also forces us to think about what we consider 'the human side of medicine'. Implications: Critical technical consciousness can be fostered through an educational program underpinned by the recognition that, although technological innovation can create new possibilities for healing, technology is never neutral. Rather, it is imperative to emphasize that technology is interwoven with the social fabric that is essential to healing. Like medication, technology can be both potion and poison.

What do you mean, 'negotiating?': Patient, physician, and healthcare professional experiences of navigating hierarchy in networks of interprofessional care.

Interprofessional collaborative practice is a phenomenon that can be fraught with power dynamics between professions, within professions, and between professionals and patients. In the literature, the dominant notion is that conflicting viewpoints and interests arising from unequal power dynamics can be resolved through negotiation. This study examined COPD patients, health professionals, and physician experiences of negotiation within 10 interprofessional collaborative COPD care teams. Physicians, patients, and healthcare professionals each had strikingly different conceptions and experiences of negotiating their perspective with other team members. Our study suggests that negotiation is an idealized notion rather than a relational process embedded in interprofessional collaborative practice. Importantly, we found that the ability and opportunity to negotiate one's perspective is heavily influenced by one's position in the workplace division of labor and professional hierarchy. We conclude that "negotiation" is only one approach among many in navigating interprofessional relations. Further, the rhetorical and ideological appeal of "negotiation" may overstate its role in interactions in interprofessional care settings, and lead to a misunderstanding of the power dynamics at play. It may be naïve to assume team members can control their situation through the competitive assertion of their individual perspective in a rational debate. Unfortunately, adopting the language of negotiation uncritically may not offer relevant solutions to structural and collective problems within a healthcare workplace.

Qualitative ego networks in health professions education: Capturing the self in relation to others.

INTRODUCTION: Our very sense of self emerges through interactions with others. As part of this State of the Science series on Self, Society, and Situation, we introduce a qualitative ego network research approach. This research approach offers insights into the self's (the ego's) interpretation of and relation to named others in the social network in question. PURPOSE: Visual mapping of participants' social networks is gaining traction, yet this research approach has received no focused attention in the health professions education (HPE) literature. A qualitative ego network approach is a compelling research approach because it uniquely maps participants' perceptions of the complex social world they are embedded in. Although many methodologies can explore participants' social world, ego networks can enhance expression of tacit knowledge of one's social environment and encourage reflection. This approach, combined with other qualitative data, can also reveal hidden relational data that the researcher may not observe or consider. To demonstrate its value as a visual methodology, we will showcase two examples of qualitative ego network studies. We then balance the paper with some critical reflections of this research approach. CONCLUSIONS: A qualitative ego network approach holds potential for deepening understanding of the self in relation to society and situation in future HPE research. We look forward to intentional, impactful and invigorated research using a qualitative ego network approach as we tackle unknowns about how self and society in specific HPE situations interact.

Patient-present teaching in the clinic: Effect on agency and professional behaviour.

BACKGROUND/PURPOSE: Although much has been written about the medical learning environment, the patient, who is the focus of care, is rarely the focus in this literature. The purpose of this study was to explore the role of the patient as an active participant with agency in the medical learning environment from the standpoint of the learner, the attending physician, and most importantly, the patient. We hoped to gain insights into the mechanisms that can reinforce professional values such as patient-centred and respectful behaviours in a patient-present learning environment. METHODS: We conducted this study in an ambulatory internal medicine clinic using 'patient-present' clinic visits. All case presentations occurred in examination rooms with the patient. We invited participants (attending physicians, undergraduate and postgraduate learners, patients and family members) to participate in semistructured interviews after each clinic visit to explore the impact of the patient-present learning environment. We recruited 34 participants in the study; 10 attending physicians, 12 learners, 10 patients and 2 family members. We analysed the data deductively using a conceptual framework of agency. SUMMARY/RESULTS: We identified three major insights: (1) Patients felt engaged and valued opportunities to be heard; (2) Attending physicians and learners reported a more respectful learning environment and a positive though challenging teaching and learning experience; and (3) A hidden curriculum emerged in a performance-based view of professional behaviour. CONCLUSIONS: Patient-present teaching engaged patients and enhanced their agency by recasting the patient as the central focus within the healthcare encounter. We identified a tension between performing and learning. This study adds new insights to the concept of patient centredness and professionalism from the perspectives of all participants in the medical teaching and learning environment.

Presenting cases in front of patients: implications for a key medical education genre.

Case presentations have been researched as both an important form of intra/inter-professional communication, where a patient's clinical information is shared among health professionals involved in their care, and an equally key discursive tool in education, where learners independently assess a patient and present the case to their preceptor and/or care team. But what happens to the case presentation, a genre that governs physician (and learner) talk about patients, when it is used in patients' presence? While they were commonly used at the bedside in the past, case presentations today are more commonly performed in hallways or conference rooms, out of patient earshot. This paper draws on interview data from a study involving patient-present case presentations in a medical education setting. Our analysis asks what participants' metageneric comments about the encounter can teach us about the genre, about patient involvement in medical education, and about linguistic adaptations to the genre that the profession might make to support patient involvement.

Ethical issues experienced by persons with rheumatoid arthritis in a wearable-enabled physical activity intervention study.

INTRODUCTION: Using wearables to self-monitor physical activity is a promising approach to support arthritis self-management. Little is known, however, about the context in which ethical issues may be experienced when using a wearable in self-management. We used a relational ethics lens to better understand how persons with rheumatoid arthritis (RA) experience their use of a wearable as part of a physical activity counselling intervention study involving a physiotherapist (PT). METHODS: Constructivist grounded theory and a relational ethics lens guided the study design. This conceptual framework drew attention to benefits, downsides and tensions experienced in a context of relational settings (micro and macro) in which participants live. Fourteen initial and eleven follow-up interviews took place with persons with RA in British Columbia, Canada, following participation in a wearable-enabled intervention study. RESULTS: We created three main categories, exploring how experiences of benefits, downsides and tensions when using the intervention intertwined with shared moral values placed on self-control, trustworthiness, independence and productivity: (1) For some, using a wearable helped to 'do something right' by taking more control over reaching physical activity goals. Some, however, felt ambivalent, believing both there was nothing more they could do and that they had not done enough to reach their goal; (2) Some participants described how sharing wearable data supported and challenged mutual trustworthiness in their relationship with the PT; (3) For some, using a wearable affirmed or challenged their sense of self-respect as an independent and productive person. CONCLUSION: Participants in this study reported that using a wearable could support and challenge their arthritis self-management. Constructing moral identity, with qualities of self-control, trustworthiness, independence and productivity, within the relational settings in which participants live, was integral to ethical issues encountered. This study is a key step to advance understanding of ethical issues of using a wearable as an adjunct for engaging in physical activity from a patient's perspective. PATIENT OR PUBLIC CONTRIBUTION: Perspectives of persons with arthritis (mostly members of Arthritis Research Canada's Arthritis Patient Advisory Board) were sought to shape the research question and interpretations throughout data analysis.

Students' social networks are diverse, dynamic and deliberate when transitioning to clinical training.

CONTEXT: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training. METHODS: Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T0 ) and then again four months later (T1 ). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed-methods analysis on this data. RESULTS: At T0 , eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1 . People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance). CONCLUSIONS: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions.

Macro and meso level influences on distributed integrated COPD care delivery: a social network perspective.

BACKGROUND: Care guidelines for people with chronic obstructive pulmonary disease (COPD) recommend an integrated approach for holistic, flexible, and tailored interventions. Continuity of care is also emphasised. However, many patients with COPD experience fragmented care. Discontinuities in healthcare and related social services are likely to result in disjointed rather than integrated care which can negatively affect patient health outcomes. The purpose of this qualitative study was to improve our understanding of, and how, contextual features pertaining to structures and processes of COPD integrated care influence delivery of care within patients' healthcare networks. METHODS: We conducted individual interviews with 28 participants (9 patients, 16 healthcare professionals, and 3 spousal caregivers). Participants were recruited through the lung clinic at a city hospital in western Canada. We employed a social network paradigm to analyse and interpret the data. RESULTS: The analysis revealed an overarching theme of fragmented COPD care with two sub-themes: (1) Funding shortfalls and availability of resources, and (2) Dis(mis)connected communication pathways. The overarching theme depicts variations, delays, and discontinuities in patient care. The sub-themes describe how macro level influences and meso level shortfalls were perceived to influence the availability of respiratory care resources that contributed to fragmented COPD care. CONCLUSIONS: Employing a social network lens drew particular attention to family physicians' pivotal role in delivering community-based COPD care. While an integrated approach to care is recommended by care guidelines, institutional and organizational structures and processes, such as financial and communication structures, may inhibit delivery of integrated care. Thus, macro and meso level structures and processes have the potential to shape patient care by constraining family physicians' purposive and communication actions necessary for facilitating an integrated distributed approach to care. We propose a context of care which fosters a context for family physicians' delivery of patient-centered care. Integrated care delivery may improve patients' wellbeing and alleviate financial constraints on the healthcare system.

Challenging the myth of the attrition of empathy in paediatrics residents.

CONTEXT: Empathy is vital to the physician-patient relationship. It promotes patient compliance and increases treatment efficacy. Studies evaluating the loss of empathy as residents advance through training curricula have generated inconsistent claims. Those considering diverse resident populations have supported a decline, whereas the few studies focused on paediatrics note stable empathy scores during training, which, indeed, exceed those of the general population. To better understand the issue as it pertains to paediatrics trainees, this study aimed to explore the state, and map a trajectory, of empathy in paediatrics residents, to identify factors influencing the learning and retention of empathy. METHODS: This qualitative descriptive study was conducted at an urban children's hospital in Canada. A total of 10 participants were recruited for semi-structured interviews via a purposeful sampling strategy. The institutional research ethics board approved the project. RESULTS: Senior residents (R3 and R4) reported increased empathy, attributable to greater knowledge regarding paediatric illnesses, according them a fuller sense of the impact on families. Challenges to sustained empathy correlated with published literature: time constraints, compassion fatigue and burnout with poor coping, and the hidden curriculum. Empathy was learned from peers, preceptors and other health care providers. Resident resilience, borne out of personal adversity, was protective against the loss of empathy. Residents advocated for increased autonomy and responsibility for patient care, and increased exposure to longitudinal care, including the patient's social context and home life, to increase resident empathy. CONCLUSIONS: Curriculum development committees could consider the inclusion of these encounters and experiences in residency training, although similar descriptive research in other specialty contexts would be needed to refine understanding.

Disabled healthcare professionals' diverse, embodied, and socially embedded experiences.

Disabled people are underrepresented within healthcare professions, although their participation has potential benefits for them personally, and for broader society. Disabled peoples' participation in healthcare professions is limited by assumptions about disability. Little research explores how healthcare professions can be organized to support disabled peoples' employment. Within a critical realist paradigm influenced by grounded theory, this study used interviews to explore the experiences of 56 disabled healthcare clinicians and students, and advance a conceptual taxonomy of disability experience within healthcare professions. Participants describe their experiences of disability in the healthcare professional context in terms of characteristics and dimensions of disability-how characteristics interact with factors within healthcare training and practice environments. We profile two particularly salient dimensions of the disability experience: visibility and onset of disability. These are developed to describe complexity and specificity of the experiences of individuals negotiating the healthcare context. Among participants there is extensive heterogeneity related to the experience of disability in healthcare professional contexts. Despite some having similar disability characteristics, no two individuals experience the same combination of characteristics and dimensions of disability. Given the complexity of experiences for disabled healthcare professionals/students, a taxonomy for conceptualizing this experience is presented. Readers are encouraged to consider the taxonomy through which they might conceptualize individual, embodied, and socially embedded experiences of disabled healthcare professionals and students. Stakeholders involved in healthcare professions and education should consider this shift in perspective, with a view to increasing access of disabled people to health professional practice.

Appropriating and asserting power on inflammatory arthritis teams: A social network perspective.

BACKGROUND: Therapeutic interventions for people with inflammatory arthritis (IA) increasingly involve multidisciplinary teams and strive to foster patient-centred care and shared decision making. Participation in health-care decisions requires patients to assert themselves and negotiate power in encounters with clinicians; however, clinical contexts often afford less authority for patients than clinicians. This disadvantage may inhibit patients' involvement in their own health care. OBJECTIVE: To identify communication attributes, IA patients use to influence and negotiate their treatment with members of their health-care network. METHOD: A qualitative social network approach was used to analyse data from a larger study that investigated IA patients' overall experiences of multidisciplinary care. Fourteen patients with IA attended individual semi-structured interviews. Researchers used thematic analysis to identify patterns of assertiveness and influence in the data. RESULTS: Participants experienced loss of identity, control and agency in addition to the physical symptoms of IA. However, they had a sense of personal responsibility for managing their health care. Perceptions of health-care team support enhanced patients' influence in treatment negotiations. Notably, there appeared to be an underlying tension between being empowered or disempowered. DISCUSSION AND CONCLUSIONS: The findings have significant implications for treatment decision communication approaches to IA care. A social network perspective may provide a pathway for clinicians to better understand the complexities of communication with their patients. This approach may reduce unequal power dynamics that occur within clinician/patient interactions and afford people with IA agency, control and affirmation of identity within their health-care network.

Understanding Experiences in Hospice: Exploring Temporal, Occupational, and Relational Dimensions Using Pictor Technique.

Temporality, occupation, and relationships are identified as discrete factors that impact quality of life for individuals at the end of life and those around them. However, scholars, practitioners, and educators require insights regarding whether and how interactions between these factors shape this quality of life. This study is framed by an understanding that meaning is negotiated between people through social interaction and occupational engagement in temporal contexts. We conducted in-depth interviews with 9 patients and 10 family members, incorporating the Pictor visual elicitation technique. Analysis was conducted through an iterative process involving open and selective coding. Findings are described as three main processes: (a) experiences of temporal rupture, (b) diminished significance of clock time, and (c) shifts in occupational priorities. Participants' perspectives may help carers understand how to foster positive temporal experiences and quality of life for patients and those who love them.

"I Can Understand Where They're Coming From": How Clinicians' Disability Experiences Shape Their Interaction With Clients.

Students and clinicians with disabilities are underrepresented in the academic health programs and professional clinical settings. Disability studies foregrounds the unique ways of knowing and being that clinicians with disabilities can offer. Based on a larger grounded theory study of the experiences of students and clinicians with disabilities, this article examines the role that clinicians' abilities to draw on their personal experiences of living with a disability have on their interactions with clients. The analysis of semistructured interviews with 55 students and clinicians with disabilities from different fields contributes to the development of a theory of epistemic connection. The theory is informed by the following three themes: (a) building rapport through understanding, (b) from understanding to advocacy and creative approaches, and (c) between professionalism and disability. The findings emphasize not only the importance of diversifying the health care workforce but also incorporating disability epistemology into the health care culture.

The Complexity of Patients' Health Communication Social Networks: A Broadening of Physician Communication.

Phenomenon: Patients have access to a wide variety of sources of information about their health in their day-to-day contexts. This can sometimes result in discordance between a physician's perception of a patient's health issue and a patient's perception of their health issue. Even after the physician has negotiated an understanding and treatment plan with a patient, subsequent interactions outside the physician-patient encounter may modify the patient's understanding of their health issue. A patient's reinterpretation of his or her health issue can then result in nonadherence of the treatment plan or even alternative treatment plans that the physician perceives as being unsatisfactory. Current models of physician-patient communication do not prepare physicians to manage this phenomenon. Approach: Using an ethnographic and a social network analysis research design, participants' patterns of social interaction around health information were investigated over a yearlong period (2012-2013) in a small rural community in Western Canada. Data included (a) individual interviews, (b) focus group interviews, and (c) field notes. Data were analyzed in a three-stage process: (a) item analysis, (b) pattern analysis, and (c) structural analysis. Findings: The findings highlight how physicians are only one nodal point in patients' broad, multilayered networks of communication. Interactions around health topics were not isolated events but rather occurred in various patterns of social interactions that were longitudinal and iterative. Meaning making around health topics was constructed, shared, elaborated, reconstructed, and interpreted in participants' social networks, as information was distributed through a complex temporal system of interpersonal ties. Insights: Issues concerning physician communication have been a long-standing conversation in the field of medical education. Many competency frameworks have attempted to encompass this core competency in their elaboration of the physician communicator. However, most representations and discussions in the field tend to depict physician communicators as experts who translate their knowledge to patients in a simplified way, in a single moment in time. This study suggests that educational initiatives in physician-patient communication would benefit from contextualizing physicians as part of patients' resource-rich, temporally extended, iterative process of meaning making. This alternative framing has the potential to support physicians' continuing engagement with patients as a meaningful and responsive node in patients' meaning-making networks.

Health literacy and chronic disease management: drawing from expert knowledge to set an agenda.

Understanding the nature and impact of health literacy is a priority in health promotion and chronic disease prevention and treatment. Health literacy comprises the application of a broad set of skills to access, comprehend, evaluate, communicate and act on health information for improved health and well-being. A complex concept, it involves multiple participants and is enacted across a wide variety of contexts. Health literacy's complexity has given rise to challenges achieving a standard definition and developing means to measure all its dimensions. In May 2013, a group of health literacy experts, clinicians and policymakers convened at an Expert Roundtable to review the current state of health literacy research and practice, and make recommendations about refining its definition, expanding its measurement and integrating best practices into chronic disease management. The four-day knowledge exchange concluded that the successful integration of health literacy into policy and practice depends on the development of a more substantial evidence base. A review of the successes and gaps in health literacy research, education and interventions culminated in the identification of key priorities to further the health literacy agenda. The workshop was funded by the UBC Peter Wall Institute for Advanced Studies, Vancouver.

The "Handling" of power in the physician-patient encounter: perceptions from experienced physicians.

BACKGROUND: Modern healthcare is burgeoning with patient centered rhetoric where physicians "share power" equally in their interactions with patients. However, how physicians actually conceptualize and manage their power when interacting with patients remains unexamined in the literature. This study explored how power is perceived and exerted in the physician-patient encounter from the perspective of experienced physicians. It is necessary to examine physicians' awareness of power in the context of modern healthcare that espouses values of dialogic, egalitarian, patient centered care. METHODS: Thirty physicians with a minimum five years' experience practicing medicine in the disciplines of Internal Medicine, Surgery, Pediatrics, Psychiatry and Family Medicine were recruited. The authors analyzed semi-structured interview data using LeCompte and Schensul's three stage process: Item analysis, Pattern analysis, and Structural analysis. Theoretical notions from Bourdieu's social theory served as analytic tools for achieving an understanding of physicians' perceptions of power in their interactions with patients. RESULTS: The analysis of data highlighted a range of descriptions and interpretations of relational power. Physicians' responses fell under three broad categories: (1) Perceptions of holding and managing power, (2) Perceptions of power as waning, and (3) Perceptions of power as non-existent or irrelevant. CONCLUSIONS: Although the "sharing of power" is an overarching goal of modern patient-centered healthcare, this study highlights how this concept does not fully capture the complex ways experienced physicians perceive, invoke, and redress power in the clinical encounter. Based on the insights, the authors suggest that physicians learn to enact ethical patient-centered therapeutic communication through reflective, effective, and professional use of power in clinical encounters.