On acknowledging silence within medical education.

INTRODUCTION: Silence is a part of all interactions, yet its potential significance within medical education remains underexplored. Existing literature primarily focuses on its use as a skill, leaving a gap in understanding its broader implications. Emerging evidence from higher education suggests that conceptualising silence as a way of being and becoming could enrich personal and professional growth. Unfolding dialogue on equality, diversity and inclusion suggests that silence on inequity can be oppressive. However, medical education has yet to consider the possible implications of conceptualising silence in this way. METHODS: We explore silence through the philosophical lens of acknowledgement. Acknowledgement-communicative behaviour that grants attention to others-is a philosophy with roots in phenomenology. It is concerned with being and becoming, and silence can be part of the communicative behaviour that constitutes acknowledgement. Our aim in exploring the ontological nature of silence (silence associated with being) using acknowledgement is to offer a springboard for practitioners, educators, and researchers to consider how silence is connected with our existence as people. RESULTS: Positive acknowledgement involves a commitment to turning towards the other and valuing this connection. Silence can be a way of demonstrating this-for example, giving patients the space they need to express their thoughts and emotions. Negative acknowledgement is the opposite and involves dismissing, ignoring or invalidating another's experiences. In the context of silence, negative acknowledgement may involve ignoring a person or group's ideas, or bystander silence when witness to discrimination. CONCLUSIONS: Within this work, we consider the ramifications of conceptualising silence as ontological, rather than purely a skill to be taught. This is a novel way of conceptualising silence, and there is a pressing need to explore this further to expand our understanding of the impact of silence for diverse groups of learners, educators, practitioners and patients.

"You may think that the consultants are great, and they know everything, but they don't": exploring how new emergency medicine consultants experience uncertainty.

BACKGROUND: Uncertainty is particularly obvious in emergency medicine (EM) due to the characteristics of the patient cohort, time constraints, and busy environment. Periods of transition are thought to add to uncertainty. Managing uncertainty is recognised as a key ability for medical practice, but is often not addressed explicitly. This study explored how new consultants in EM experience uncertainty, with the aim of making explicit what is often hidden and potentially informing support for doctors to manage the uncertainty they face. METHODS: This was a qualitative study using interpretive phenomenological analysis (IPA). Five consultants working in the UK within one year of achieving a certificate of completion of training were interviewed online during 2021, these were transcribed and analysed using IPA. RESULTS: Three superordinate themes were identified: 'transition and performance as a source of uncertainty', 'uncertainty and decision-making in the context of the emergency department' and 'sharing uncertainty and asking for help'. The transition created uncertainty related to their professional identity that was compounded by a lack of useful feedback. There was tension between perceived expectations of certainty and the recognition of uncertainty in practice. EM doctors were seen as experts in managing uncertainty, with responses to uncertainty including gathering information, sharing uncertainty and seeking help. Expressing uncertainty was viewed as necessary for good patient care but could be risky to credibility, with psychological safety and role modelling behaviour making it easier for the participants to express uncertainty. CONCLUSION: This study highlights the need for new consultants to have psychologically safe, reflective spaces to think through uncertainties with others. This appears to reduce uncertainty, and also act as a source of feedback. The study adds to the existing calls to address uncertainty more explicitly in training, and challenge the expectations of certainty that exist within medicine.

Training for difficult conversations and breaking bad news over the phone in the emergency department.

Due to the COVID-19 pandemic, there have been strict limits on visitors to hospitals. This has led to clinicians having an increasing number of difficult conversations with patients and their relatives over the phone. There is a lack of published literature examining how to do this well, but it is recognised that phone communication does differ from face to face interactions, and requires specific training. What is most important to patients and their families when receiving bad news is privacy, adequate time without interruptions, clarity and honesty when delivering the information, and an empathetic and caring attitude. Much of the work done on breaking bad news has been done in oncology and focusses on face to face interaction; there has been an assumption that this is transferrable to the emergency department, and more recently that this is applicable to conversations over the phone. Multiple educational interventions to improve the delivery of bad news have been developed, with differing frameworks to help clinicians carry out this stressful task. Simulation is widely used to train clinicians to break bad news, and has solid theoretical foundations for its use. The psychological safety of participants must be considered, especially with emotive subjects such as breaking bad news. We believe there is a need for specific training in breaking bad news over the phone, and developed an innovative simulation-based session to address this. The training has been well received, and has also highlighted the need for a space where clinicians feel able to discuss the emotional impact of the difficult conversations they are having.