Highlights • This research provides a rich description of caring. • Patients experienced caring when competent professionals communicated effectively. • They did so also, when professionals formed ...relationships, engaged emotionally, and displayed positive attitudes. • These findings could underpin education for collaborative, interprofessional practice.
The authors explore the power dynamics at play in inter‐professional education to ask the question ‘should we sanction or support inter‐professional workplace learning and practice?’
The problem: Clinical practice commonly presents new doctors with situations that they are incapable of managing safely. This harms patients and stresses the new doctors and other clinicians. ...Unpreparedness for practice remains a problem despite changes in curricula from apprenticeship to outcome-based designs. This is unsurprising because capability depends on learning from practical experience in supportive learning environments. To assure the care of patients and well-being of residents, the pedagogy of medical students' practice-based education is in urgent need of an overhaul.
This Guide: Experience based learning (ExBL) is a 21
st
century pedagogy of practice-based learning, derived from best current theory and evidence. ExBL specifies capabilities that medical students need to acquire from practical experience. It exemplifies how clinicians' behavior can help students gain experience. It explains how reflection converts real patient learning into capability and identity. It identifies desirable features of learning environments. This Guide advises clinicians, students, placement leads, faculty developers, and other stakeholders how to make new doctors as capable as possible. ExBL is a comprehensive model of medical students' practice-based learning, which complements competency-based education to prepare new doctors to deliver safe, effective, and compassionate care.
Background
Ensuring that students transition smoothly into the identity of a doctor is a perpetual challenge for medical curricula. Developing professional identity, according to cultural‐historical ...activity theory, requires negotiation of dialectic tensions between individual agency and the structuring influence of institutions. We posed the research question: How do medical interns, other clinicians and institutions dialogically construct their interacting identities?
Methods
Our qualitative methodology was rooted in dialogism, Bakhtin's cultural‐historical theory that accounts for how language mediates learning and identity. Reasoning that the COVID pandemic would accentuate and expose pre‐existing tensions, we monitored feeds into the Twitter microblogging platform during medical students' accelerated entry to practice; identified relevant posts from graduating students, other clinicians and institutional representatives; and kept an audit trail of chains of dialogue. Sullivan's dialogic methodology and Gee's heuristics guided a reflexive, linguistic analysis.
Results
There was a gradient of power and affect. Institutional representatives used metaphors of heroism to celebrate ‘their graduates’, implicitly according a heroic identity to themselves as well. Interns, meanwhile, identified themselves as incapable, vulnerable and fearful because the institutions from which they had graduated had not taught them to practise. Senior doctors' posts were ambivalent: Some identified with institutions, maintaining hierarchical distance between themselves and interns; others, along with residents, acknowledged interns' distress, expressing empathy, support and encouragement, which constructed an identity of collegial solidarity.
Conclusions
The dialogue exposed hierarchical distance between institutions and the graduates they educated, which constructed mutually contradictory identities. Powerful institutions strengthened their identities by projecting positive affects onto interns who, by contrast, had fragile identities and sometimes strongly negative affects. We speculate that this polarisation may be contributing to the poor morale of doctors in training and propose that, to maintain the vitality of medical education, institutions should seek to reconcile their projected identities with the lived identities of graduates.
How did new clinicians shape their identities during the pandemic? Twitter reveals a complex dialogue in which institutions tout heroism while interns express vulnerability. Bridging these identity gaps is key to nurturing the morale of doctors‐in‐training.
Prescribing is a common task, often performed by junior clinicians, with potential for significant harm. Despite this, it is common for medical students to qualify having only prescribed in simulated ...scenarios or assessments. We implemented an alternative: students were given pens with purple ink, which permitted them to write prescriptions for real patients. We set out to understand how this intervention, pre-prescribing, created a zone of proximal development (ZPD) for learners.
An anonymous, mixed methods, evaluation questionnaire was distributed to all final-year medical students at one university in the United Kingdom. Analysis was guided by Experience Based Learning theory.
Two hundred and eighteen students made 386 free-text comments. Most participants reported that pre- helped them become capable doctors (Strongly Agree n = 96, 45%; Agree: n = 110, 50%). Pre-prescribing created a ZPD in which participants could use the tools of practice in authentic contexts under conditions that made it safe to fail.
This research shows how a theoretically informed intervention can create conditions to enhance learning. It encourages educators to identify aspects of routine practice that could be delegated, or co-performed, by learners. With appropriate support, educators can create 'safe-fails' which allow learners to participate safely in authentic, risky, and indeterminate situations they will be expected to navigate as newly qualified clinicians.
Clinical education research (ClinEdR) is a growing field that aims to ensure the way healthcare professionals are taught and learn is evidence‐based. There is growing interest in how this evidence is ...generated in a robust, timely and cost‐effective fashion. In this ‘How to …’ paper, we draw on relevant literature and our own experiences to offer suggestions on how novice researchers can navigate entry into the field of ClinEdR. We summarise key resources for those at the earliest stages of their interest in ClinEdR and scholarship and provide personal experiences of networking, collaborating and balancing research with a clinical or teaching role. This paper will be of interest to those at any stage in their clinical career with little to no experience of ClinEdR, but the enthusiasm to get started.
Context
Peabody's maxim ‘the secret of the care of the patient is in caring for the patient’ inspired generations of doctors to relate humanely to patients. Since then, phrases such as ‘managed care’ ...have impersonalised caring. The term ‘patient‐centred’ was introduced to re‐personalise caring. Ironically, however, such terms have been defined by professionals’ preconceptions rather than patients’ experiences. Using patients’ experiences of doctors being (un)caring to guide doctors’ learning could reinvigorate caring. Interpretive phenomenology provides qualitative research tools with which to do this.
Methods
Ten patients, purposively selected to have broad experiences of primary, secondary and tertiary health care, consented to participate. To stay close to their lived experiences, participants first drew ‘Pictor’ diagrams to represent relationships between themselves and professionals during remembered experiences of (un)caring. A researcher then used the depictions to structure in‐depth, one‐to‐one explorations of the lived experience of caring. Verbatim transcripts were analysed using template analysis. To remain very close to patients’ experiences, the researchers assembled a narrative description of the phenomenon of caring using participants’ own words.
Results
Caring doctors were genuine. They allowed their own individuality to interact with patients’ individuality. This made participants feel recognised as individuals, not just diseases. Caring doctors listened and spoke carefully, encouraged expressions of emotion, were accessible and responsive, and formed relationships. These factors empowered participants to be actively involved in their own care. Little things like smiling, shaking hands, admitting uncertainty, asking a colleague for advice and calling a participant unexpectedly at home showed that doctors were prepared to ‘go above and beyond’. This was caring.
Conclusions
These findings provide medical educators with an interpretation of caring that is truly patient‐centred. Coupling technical proficiency with human qualities – being genuinely empathic and respectful – within doctor–patient relationships is the essence of caring.
Gillespie and colleagues propose caring to be an essential yet indefinable quality of doctors. Technical medical interventions and competence alone are of less value if clinicians do not humanise patients’ experiences of care.
The hope that reliably testing clinicians' competencies would improve patient safety is unfulfilled and clinicians' psychosocial safety is deteriorating. Our purpose was to conceptualise 'mutual ...safety', which could increase benefit as well as reduce harm.
A cultural-historical analysis of how medical education has positioned the patient as an object of benefit guided implementation research into how mutual safety could be achieved.
Educating doctors to abide by moral principles and use rigorous habits of mind and scientific technologies made medicine a profession. Doctors' complex attributes addressed patients' complex diseases and personal circumstances, from which doctors benefited too. The patient safety movement drove reforms, which reorientated medical education from complexity to simplicity: clinicians' competencies should be standardised and measurable, and clinicians whose 'incompetence' caused harm remediated. Applying simple standards to an increasingly complex, and therefore inescapably risky, practice could, however, explain clinicians' declining psychosocial health. We conducted a formative intervention to examine how 'acting wisely' could help clinicians benefit patients amidst complexity. We chose the everyday task of insulin therapy, where benefit and harm are precariously balanced. 247 students, doctors, and pharmacists used a thought tool to plan how best to perform this risky task, given their current clinical capabilities, and in the sometimes-hostile clinical milieus where they practised. Analysis of 1000 commitments to behaviour change and 600 learning points showed that addressing complexity called for a skills-set that defied standardisation. Clinicians gained confidence, intrinsic motivation, satisfaction, capability, and a sense of legitimacy from finding new ways of benefiting patients.
Medical education needs urgently to acknowledge the complexity of practice and synergise doctors' and patients' safety. We have shown how this is possible.
PDF
