Leaders' perspectives and actions to manage challenges in medical education presented by the COVID-19 pandemic: a nationwide survey of Japanese medical colleges.

BACKGROUND: The COVID-19 pandemic has caused medical colleges worldwide to suspend in-person classes and clinical clerkships. This fluid situation urgently required educators and learners to make a paradigm shift from traditional medical education. However, descriptions of how leaders manage policy decisions, especially considering cultural contexts, are limited. This study explores how the deans of medical colleges in Japan addressed the situations in which face-to-face contact is difficult and interacted with various stakeholders during the COVID-19 pandemic. METHODS: The study employed a nationwide online survey by sending individual e-mails to the director of medical education at each of the 82 medical colleges in Japan. Responses were collected between May 26 and June 12, 2020 from the deans or directors of medical education. The survey questions were developed based on a literature review and consultations with international research collaborators. The survey asked what difficulties and opportunities were encountered through curriculum adjustments during the COVID-19 pandemic and what lessons could be shared with medical educators worldwide. Survey responses were analyzed using thematic analysis. The themes were categorized by stakeholder and then analyzed using the domains of sensemaking theory. RESULTS: A total of 48 medical colleges in Japan completed the survey, yielding a response rate of 58.5%. The levels of participation in the study were 42.9%, 77.8%, and 74.2% among national, public, and private medical colleges, respectively, with responses from public and private medical colleges tending to be higher than those from national medical colleges. Japanese deans' decisions for actions in adapting to COVID-19 involve perceiving cues from multiple stakeholder groups, including medical students, parents of medical students, medical faculties, and government officials. Thematic analysis of survey data reveals that Japanese deans' actions in adapting to COVID-19 reflect characteristics of Japanese culture, with Japanese deans tending to emphasize in-depth introspection and collaboration with diverse stakeholders. CONCLUSIONS: Despite a lack of clear national guidelines for decision making, Japanese deans adapted to COVID-19 challenges by learning from one another and seeking the perspectives of a diverse group of stakeholders, aligned with local cultural context. Their approach offers important lessons for global medical educators.

Public availability of information from WFME-recognized accreditation agencies.

The World Federation for Medical Education (WFME) Recognition Programme was created to ensure the comparability of medical school accrediting agencies, so that the schools accredited by those agencies would have similar educational quality. WFME explicitly values transparency and has recognition criteria that relate to agencies making information publicly available. Our study examined 20 WFME-recognized agencies' transparency by reviewing agency websites for 27 information elements related to accreditation standards, procedures, and processes. We contacted agencies as needed for information that we could not find on their websites. We were only able to retrieve additional information from 3 of the 12 agencies that we attempted to contact. We found that while 12 agencies had over 90% of expected information elements available, 6 agencies had less than 50%. Our findings illustrate barriers for those who wish to better understand medical school accreditation in some regions and raise questions about how comparable WFME-recognized agencies are.

When patient-centred and family-centred approaches clash: Taiwanese health professions students' patient autonomy dilemmas.

The main purpose of the study was to examine whether health professions students in Taiwan who study in different programmes experience similar patient autonomy-related professionalism dilemmas caused by disconnections between school and clinical culture. To investigate this issue, we draw specifically on situated learning theory and its cultural concept to examine their professionalism dilemma narratives that were collected through interviews. Of the 79 interviewed students, nearly half of them experienced patient autonomy dilemmas caused by conflicts between school and clinical culture, which have significant negative impacts on their learning and emotional wellbeing. Four major types of patient autonomy-related dilemmas emerge from the data. It was also found that when school culture and clinical culture clash, the latter has a greater influence on students. Thus, the study argues that Taiwanese students' frequent encounters with patient-autonomy dilemmas highlight the challenges faced by health professions students in transferring knowledge between school and clinical cultures, and clinical culture has a more powerful influence on their behaviour and clinical decision making. This phenomenon should be taken into account when organizing health professions education.

A SWOT analysis of Italian medical curricular adaptations to the COVID-19 pandemic: A nationwide survey of medical school leaders.

BACKGROUND: There is a growing literature on how medical education adapts to the COVID-19 pandemic. However, there is a need to examine the facilitators and barriers of these adaptations. This study explores the strengths, weaknesses, opportunities, and threats (SWOT) of how Italian medical schools adapted their curricula to the COVID -19 pandemic. METHODS: The authors conducted an online survey of directors of medical curricula in Italy. Free-text responses to open-ended questions about curricular adaptations and reflections on these adaptations were analysed using qualitative thematic analysis. RESULTS: Twenty out of 60 Italian medical school directors completed the survey. Strengths identified were rapid responses and a spirit of cooperation. Weaknesses included dependency on clinical facilities, teachers' limited skills to use technology, and lack of mental health support for staff. Opportunities highlighted were clear government rules, new ways of teaching and a renewed focus on underrepresented topics. Threats expressed included impaired relationships, difficulties related to online assessment, lack of IT access, and legal and insurance issues. CONCLUSIONS: This study, in documenting the curricular adaptations of Italian medical schools during an active global pandemic, and recording the perspectives of medical education leaders, offers important lessons for the future.

Female victims and female perpetrators: medical students' narratives of gender dynamics and professionalism dilemmas.

Medicine is a gendered discipline, in which women, both as patients and practitioners, have often held subordinate positions. The reproduction of dominant gender biases in the medical setting can negatively impact the professional development of medical students and the wellbeing of patients. In this analysis of medical students' narratives of professionalism dilemmas, we explore students' experiences of gender bias in hospital settings. Seventy-one students participated in 12 group interviews, where they discussed witnessing or participating in various activities that they thought were professionalism lapses. Within the dataset, 21 narratives had a distinctly gendered component broadly pertaining to patient dignity and safety dilemmas, informed consent issues, and female student abuse. Interestingly, perpetrators of such acts were commonly female healthcare professionals and educators. Although students recognized such acts as professionalism lapses and often expressed concern for patient wellbeing, students did not intervene or report such acts due to hierarchical cultural contexts, and at times even reproduced the discriminatory behavior they were criticizing. This raises concerns about medical students' professionalism development and the extent to which gender bias is ingrained within particular medical systems. The normalization of disrespectful and abusive treatment of female patients poses immediate and future consequences to the wellbeing and safety of women. Furthermore, the same socio-cultural values that sustain these acts may account for perpetrators often being women themselves as they strive to overcome their subordinate position within medicine.

Faculty perceptions of student plagiarism and interventions to tackle it: a multiphase mixed-methods study in Qatar.

BACKGROUND: The widespread use of the internet and other digital resources has contributed to the escalation of plagiarism among medical students and students of other healthcare professions. Concerns were raised by faculty at Weill Cornell Medicine-Qatar (WCM-Q), a branch of Weill Cornell Medicine of Cornell University in New York, who had been observing plagiarism in students' assignments. METHODS: To identify the extent of plagiarism practices and their contributing factors, a two-phase mixed-method research study was conducted, comprising a survey administered in 2013, followed by longitudinal interventions, and a second survey in 2017 to measure the impact of the interventions. RESULTS: By Phase II, overall observed plagiarism incidents per year decreased from 44 to 28%, and the number of faculty who observed no plagiarism incidents increased significantly from 12 to 37%. The faculty concerned about student plagiarism decreased by 33% [53.1 to 20%] between Phase I and Phase II. CONCLUSION: When students are provided with information regarding what constitutes plagiarism and their institution's policy in response to plagiarism incidents, they are less likely to engage in such practices.

Professionalism dilemmas experienced by health professions students: a cross-sectional study.

Health professions students will invariably confront professionalism dilemmas. These early encounters significantly influence future professional attitudes and behaviours. Heretofore, studies concerning professionalism dilemmas experienced by health professions students across disciplines have been limited. To address this issue, we recruited 56 students with clinical experience from the National Taiwan University College of Medicine in the nursing, dentistry, pharmacy, medical technology, occupational therapy, and physiotherapy programs to participate in this research to compare health professions students' understandings of professionalism and their experiences of professionalism dilemmas. We used group interviews to uncover students' experiences of professionalism dilemmas. We identified the six most commonly reported professionalism dilemmas and found that interprofessional dilemmas were the dominant workplace professionalism dilemma for health professions students. We also identified significant disciplinary differences regarding dilemma types and frequencies. We employed the framework of dual identity development to better understand the role of professional and interprofessional identities in interprofessional dilemmas. The professionalism dilemmas that individual students encountered were shaped by disciplinary differences. Our findings suggest that the development of a sense of belonging to both their own profession and a broader interprofessional care team in health professions students can increase the effectiveness of interprofessional healthcare teams.

Taiwanese and Sri Lankan students' dimensions and discourses of professionalism.

CONTEXT: The definition of medical professionalism poses a challenge to global medical educators. This is especially pronounced in settings where professionalism frameworks developed in the west are transferred into different cultures. Building upon our previous study across Western contexts, we examine Taiwanese and Sri Lankan medical students' conceptualisations of professionalism in terms of what professionalism comprises (i.e. dimensions) and how it is linguistically framed (i.e. discourses). METHODS: A qualitative group interview study was undertaken comprising 26 group interviews with 135 participants from one Taiwanese (n = 64; Years 4-7) and one Sri Lankan medical school (n = 71; Years 2-5). Through thematic framework analysis we examined the data for explicit dimensions of professionalism. Through discourse analysis we identified how participants constructed professionalism linguistically (discourses). RESULTS: Thirteen common dimensions across Taiwanese and Sri Lankan talk were identified, with the dimensions (contextual, integration and internalised self) being identified only in Sri Lankan data. Professionalism as knowledge and patient-centredness were dominant dimensions in Taiwan; in Sri Lanka, attributes of the individual and rules were dominant dimensions. Participants in both countries used four types of discourses previously identified in the literature. Individual and interpersonal discourses were dominant in Taiwanese talk; the collective discourse was dominant in Sri Lankan talk. Findings were compared with our previous data collected in Western contexts. CONCLUSIONS: Despite some overlap in the dimensions and discourses identified across both this and Western studies, Taiwanese and Sri Lankan students' dominant dimensions and discourses were distinct. We therefore encourage global medical educators to look beyond a one-size-fits-all approach to professionalism, and to recognise the significance of context and culture in conceptualisations of professionalism.

Taiwanese medical students' narratives of intercultural professionalism dilemmas: exploring tensions between Western medicine and Taiwanese culture.

In an era of globalization, cultural competence is necessary for the provision of quality healthcare. Although this topic has been well explored in non-Western cultures within Western contexts, the authors explore how Taiwanese medical students trained in Western medicine address intercultural professionalism dilemmas related to tensions between Western medicine and Taiwanese culture. A narrative interview method was employed with 64 Taiwanese medical students to collect narratives of professionalism dilemmas. Noting the prominence of culture in students' narratives, we explored this theme further using secondary analysis, identifying tensions between Western medicine and Taiwanese culture and categorizing students' intercultural professionalism dilemmas according to Friedman and Berthoin Antal's 'intercultural competence' framework: involving combinations of advocacy (i.e., championing one's own culture) and inquiry (i.e., exploring one's own and others' cultures). One or more intercultural dilemmas were identified in nearly half of students' professionalism dilemma narratives. Qualitative themes included: family relations, local policy, end-of-life care, traditional medicine, gender relations and Taiwanese language. Of the 62 narratives with sufficient detail for further analysis, the majority demonstrated the 'suboptimal' low advocacy/low inquiry approach (i.e., withdrawal or inaction), while very few demonstrated the 'ideal' high advocacy/high inquiry approach (i.e., generating mutual understanding, so 'intercultural competence'). Though nearly half of students' professionalism narratives concerned intercultural dilemmas, most narratives represented disengagement from intercultural dilemmas, highlighting a possible need for more attention on intercultural competence training in Taiwan. The advocacy/inquiry framework may help educators to address similar disconnects between Western medicine and non-Western cultures in other contexts.

Can student self-ratings be compared with peer ratings? A study of measurement invariance of multisource feedback.

Measurement invariance is a prerequisite for comparing measurement scores from different groups. In medical education, multi-source feedback (MSF) is utilized to assess core competencies, including the professionalism. However, little attention has been paid to the measurement invariance of assessment instruments; that is, whether an instrument holds the same meaning across different rater groups. To examine the measurement invariance of the National Taiwan University professionalism MSF (NTU P-MSF) in order to determine whether medical students' self-rating can be compared to their peers' rating. An eight-factor model was specified for confirmatory factor analysis to examine the construct validity of the NTU P-MSF. Cronbach's alpha was computed for the items of each domain to evaluate internal consistent reliability. The same eight-factor model was used for multi-group confirmatory factor analyses. Four hierarchical models were specified to test configural (i.e., identical factor-item relationship), metric (i.e., identical factor loadings), scalar (i.e., identical intercepts), and error variance across self-rating and peer rating groups. One hundred and twenty second-year medical students from weekly discussion groups conducted as part of a medical professionalism course agreed to use the NTU P-MSF to assess themselves or their discussion group peers. NTU P-MSF assessment scores were a good fit for the eight-factor model among self group and peer group. The Cronbach's alpha coefficients of students' NTU P-MSF scores and peers' scores ranged from 0.76 to 0.89 and 0.84 to 0.91, respectively indicating that the NTU P-MSF scores also have good internal consistent reliability between both groups. In addition, same factor structure and similar factor loadings and intercepts of NTU P-MSF scores between both groups indicate that NTU P-MSF scores had configural, metric, and scalar invariance. Thus, students' self-assessments and peer assessments can be compared in terms of the constructs of NTU P-MSF scores, change in NTU P-MSF scores, and its factor scores. This study demonstrates how to investigate the measurement invariance of a professionalism MSF and contributes to the discussion on self- and peer assessment in medical education.

A scoping review of medical professionalism research published in the Chinese language.

BACKGROUND: The Chinese Medical Doctors Association (CMDA) adopted the Charter of Medical Professionalism in the New Millennium (Charter) and published the Chinese Medical Doctor Declaration (Declaration). This is an important step to re-building medical professionalism in China at a time when the commercialization of health care has led to a decline in physician accountability and public trust in the profession. In response, authors have begun to examine and promote medical professionalism in China. This study aims to present the key research themes, identify research gaps and offer recommendations from reviewing the increasing pool of Chinese-language literature on medical professionalism. METHODS: A scoping review of Chinese language papers was conducted using the China National Knowledge Infrastructure (including China Academic Journals Full-text Database, China Doctoral Dissertations Full-text Database, Masters' Theses Full-text Database, China Core Newspapers Full-text Database, and China Yearbooks Full-text Database) (CNKI) database. RESULTS: Four major research themes were identified in Chinese discourse: (1) teaching professionalism, (2) practicing professionalism, (3) conceptualizing professionalism and (4) assessing professionalism. Overall, authors were concerned with the cultivation of humanism in physicians and emphasized the importance of communication skills to improve the physician-patient relationship in China. They explored the role of traditional Chinese values, such as Confucian and Taoist values, as well as the Communist Party's political values, in promoting professional behaviour. CONCLUSIONS: Authors demonstrate increasing interest in medical professionalism in China. The literature is of variable quality and further empirical studies are required in order to evaluate teaching interventions and guide professionalism assessment. A common professionalism framework is absent and could be developed with consideration to China's socio-cultural context.

Equal, global, local: discourses in Taiwan's international medical graduate debate.

CONTEXT: With the globalisation of medicine, the role of international medical graduates (IMGs) has expanded. Nonetheless, the experiences of native-born IMGs remain under-researched. In Taiwan, public controversy has unfolded around IMGs educated in Poland, calling into question the meaning(s) of equality in policy and medicine. In focusing on the return of IMGs to their countries of origin, this study adds to the growing literature concerning equality and globalisation in medical education. OBJECTIVES: The primary research aim was to analyse how stakeholders in the IMG debate use equality in their arguments. The authors set out to frame the dispute within the recent history of Taiwanese medical governance. An overarching objective was to contribute a critical, historical view of how discourses of globalisation and equality construct different policy approaches to international medical education. METHODS: The authors performed a critical discourse analysis of a public policy dispute in Taiwan, assembling an archive from online interactions, government reports and news articles. Coding focused on stakeholders' uses of equality to generate broader discourses. RESULTS: International and domestic Taiwanese students conceived of equality differently, referencing both 'equality of opportunity' and 'equality of outcome' within localisation and globalisation frameworks, respectively. The dominance of localisation discourse is reflected in hostile online rhetoric towards Poland-educated IMGs. CONCLUSIONS: Rhetorical disagreements over equality in medical education trace shifting state policies, from earlier attempts to remove barriers for IMGs to the present-day push to regulate IMGs for acculturation and quality assurance. The global Internet had a double-sided influence, facilitating both democratic political mobilization and the spread of hate speech. The policy debate in Taiwan mirrors discourses in Canada, where IMGs are likewise conceived either as globally competent physicians or as lacking in merit and technical competence. Future research could investigate the discursive formation and evidential basis of policies regulating international medical education.

A comparative study of professional and interprofessional values between health professional associations.

The need for effective interprofessional collaboration to ensure safe patient care is crucial. However, health professions are guided by separate professional codes of conduct. To examine whether professional codes are consistent across professions, this review examines 13 key health professional associations in the United States and compares their values to the guiding principles of interprofessional practice defined by the Interprofessional Professionalism Collaborative (IPC). Findings indicate that all six of the IPC's principles (altruism/caring, excellence, ethics, respect, communication, and accountability) were shared by the majority of professions, with many emphasizing two additional attributes, integrity and justice, suggesting there is room to expand the IPC's core principles. Few associations included interprofessional communication and collaboration in their professional codes. There is potential for associations to promote greater interprofessional collaboration by reshaping their professional frameworks. With many shared values across professions, establishing a common framework of interprofessional professionalism is feasible.

Building a professionalism framework for healthcare providers in China: a nominal group technique study.

BACKGROUND: Medical professionalism is valued globally. However, Western frameworks of medical professionalism may not resonate with the cultural values of non-Western countries. AIMS: This study aims to formulate a professionalism framework for healthcare providers at Peking Union Medical College (PUMC) in China. METHODS: This study was conducted using nominal group technique (NGT) in a convenient sample of 97 participants at PUMC in November and December, 2011. Participants were sorted into 13 occupational groups, each discussing and ranking categories of medical professionalism. The authors compared the results of each group's ranked categories and analyzed meeting transcripts. RESULTS: A pre-existing framework provided eight categories: clinical competence, communication, ethics, humanism, excellence, accountability, altruism, and integrity. Participants created four categories: teamwork, self-management, health promotion, and economic considerations. Clinical competence and communication ranked highly among most groups. Only hospital volunteers and resident physicians included self-management in their top-ranked items. Only public health experts prioritized health promotion. Standardized patients were unique in mentioning "economic considerations." Medical students and attending physicians both referenced Chinese traditional values. CONCLUSIONS: Our study was able to document effects of East Asian cultural influences and conflicts between Western ideologies and Asian traditions that led to divergent interpretations of medical professionalism.

Digging Deeper, Zooming Out: Reimagining Legacies in Medical Education.

Although the wide-scale disruption precipitated by the COVID-19 pandemic has somewhat subsided, there are many questions about the implications of such disruptions for the road ahead. This year's Research in Medical Education (RIME) supplement may provide a window of insight. Now, more than ever, researchers are poised to question long-held assumptions while reimagining long-established legacies. Themes regarding the boundaries of professional identity, approaches to difficult conversations, challenges of power and hierarchy, intricacies of selection processes, and complexities of learning climates appear to be the most salient and critical to understand. In this commentary, the authors use the relationship between legacies and assumptions as a framework to gain a deeper understanding about the past, present, and future of RIME.

Professional Identity Formation of Basic Science Medical Educators: A Qualitative Study of Identity Supports and Threats.

PURPOSE: Basic science medical educators (BSME) play a vital role in the training of medical students, yet little is known about the factors that shape their professional identities. This multi-institutional qualitative study investigated factors that support and threaten the professional identity formation (PIF) of these medical educators. METHOD: A qualitative descriptive study was conducted with a purposive sample of 58 BSME from 7 allopathic medical schools in the U.S. In-depth semi-structured interviews of individual BSME were conducted between December 2020 and February 2021 to explore the facilitators and barriers shaping the PIF of BSME. Thematic analysis was conducted. RESULTS: Factors shaping PIF were grouped into 3 broad domains: personal, social, and structural. Interrelated themes described a combination of factors that pushed BSME into teaching (early or positive teaching experiences) and kept them there (satisfaction and rewards of teaching, communities of like-minded people), as well as factors that challenged their PIF (misunderstanding from medical students, clinical, and research faculty, lack of formal training programs, and lack of tenure-track educator positions). The structural environment was reported to be crucial for PIF and determined whether BSME felt that they belonged and were valued. CONCLUSIONS: This study shows that although most BSME derive a sense of fulfillment and meaning from their role as medical educators, they face considerable obstacles during their PIF. Structural change and support are needed to increase recognition, value, promotion, and belonging for BSME to improve the satisfaction and retention of this important group of faculty.

A cross-cultural study of students' approaches to professional dilemmas: sticks or ripples.

CONTEXT: Medical educators internationally are faced with the challenge of teaching and assessing professionalism in their students. Some studies have drawn attention to contextual factors that influence students' responses to professional dilemmas. Although culture is a significant contextual factor, no research has examined student responses to professional dilemmas across different cultures. METHODS: Semi-structured interviews inquiring into reactions towards, and reasoning about, five video clips depicting students facing professional dilemmas were conducted with 24 final-year medical students in Taiwan. The interviews were transcribed and analysed according to the theoretical framework used in prior Canadian studies using the same videos and interview questions. RESULTS: The framework from previous Canadian research, including the components of principles, affect and implications, was generally applicable to the decision making of Taiwanese students, with some distinctions. Taiwanese students cited a few more avowed principles. Taiwanese students emphasised an additional unavowed principle that pertained to following the advice of more senior trainees. In addition to implications for patients, team members or themselves, Taiwanese students considered the impact of their responses on multiple relationships, including those with patients' families and alumni residents. Cultural norms were also cited by Taiwanese students. CONCLUSIONS: Medical educators must acknowledge students' reasoning in professionally challenging situations and guide students to balance considerations of principles, implications, affects and cultural norms. The prominence of Confucian relationalism in this study, exhibited by students' considerations of the rippling effects of their behaviours on all their social relationships, calls for further cross-cultural studies on medical professionalism to move the field beyond a Western individualist focus.

Defiance, compliance, or alliance? How we developed a medical professionalism curriculum that deliberately connects to cultural context.

BACKGROUND: In the age of globalization, non-Western medical educators seem too eager to conform to Western educational approaches and may, thereby, undermine the pursuit of local curricular needs. AIMS: To develop a medical professionalism curriculum that explicitly considered local cultural needs and social expectations. METHOD: We used a systematic six-step approach to develop the curriculum. RESULTS: We engaged local stakeholders (physicians, allied health professionals, and members of the public) in a nominal group process to identify professionalism competencies. Students and faculty participated in a survey and/or focus groups to determine learner/faculty needs. Teachers drafted goals and objectives related to locally valued competencies. We designed and implemented educational strategies to develop students' competencies that meet local societal expectations, such as involving family members in decision making. We plan to use multi-source feedback and a portfolio to assess students, which reinforces a definition of integrity that encompasses not only congruence between individual values and behaviors, but also achieving harmony among all stakeholders. We plan to reinforce the formal curriculum with faculty development and attention to the hidden curriculum. CONCLUSIONS: Based upon our experience and reflection, we offer some practical methods for integrating local cultural values and societal needs in professionalism education.

Assessment of professionalism: recommendations from the Ottawa 2010 Conference.

Over the past 25 years, professionalism has emerged as a substantive and sustained theme, the operationalization and measurement of which has become a major concern for those involved in medical education. However, how to go about establishing the elements that constitute appropriate professionalism in order to assess them is difficult. Using a discourse analysis approach, the International Ottawa Conference Working Group on Professionalism studied some of the dominant notions of professionalism, and in particular the implications for its assessment. The results presented here reveal different ways of thinking about professionalism that can lead towards a multi-dimensional, multi-paradigmatic approach to assessing professionalism at different levels: individual, inter-personal, societal-institutional. Recommendations for research about professionalism assessment are also presented.