The complexity of physician power.

Inequitable variation in physician effort and resource use is revealed.

Is There a Problem With Evidence in Health Professions Education?

ABSTRACT: What constitutes evidence, what value evidence has, and how the needs of knowledge producers and those who consume the knowledge produced as evidence might be better aligned are questions that continue to challenge the health sciences. In health professions education (HPE), debates on these questions have ebbed and flowed with little sense of resolution or progress. In this article, the authors explore whether there is a problem with evidence in HPE using thought experiments anchored in Argyris' learning loops framework.From a single-loop perspective ("How are we doing?"), there may be many problems with evidence in HPE, but little is known about how research evidence is being used in practice and policy. A double-loop perspective ("Could we do better?") suggests expectations of knowledge producers and knowledge consumers might be too high, which suggests more systemwide approaches to evidence-informed practice in HPE are needed. A triple-loop perspective ("Are we asking the right questions?") highlights misalignments between the dynamics of research and decision-making, such that scholarly inquiry may be better approached as a way of advancing broader conversations, rather than contributing to specific decision-making processes.The authors ask knowledge producers and consumers to be more attentive to the translation from knowledge to evidence. They also argue for more systematic tracking and audit of how research knowledge is used as evidence. Given that research does not always have to serve practical purposes or address the problems of a particular program or institution, the relationship between knowledge and evidence should be understood in terms of changing conversations, as well as influencing decisions.

Experiences of an Online Palliative Rehabilitation Programme for Spousal Caregivers of People With Amyotrophic Lateral Sclerosis and Cognitive and/or Behavioural Impairments: A Qualitative Interpretive Study.

Purpose: The purpose of this study was to understand how spousal caregivers of people with amyotrophic lateral sclerosis and cognitive and/or behavioural impairments felt about the EMBRACE intervention. Materials and methods: A qualitative interpretive study, using individual semi-structured interviews pre- and post-participation in a palliative rehabilitation blended learning programme, was applied. In total, 13 spousal caregivers were interviewed pre-intervention and 10 of them post-intervention. Results: Three overarching themes were identified: Striving to Obtain Control in Everyday Life, Peer support Across the Illness Trajectory and The Complexity of Relations. Information provided in targeted videos and sharing experiences with peers in virtual group meetings were beneficial to comprehend, manage and find meaning in everyday challenges related to being a caregiver. Conclusion: The EMBRACE intervention helped spousal caregivers cope with everyday needs and challenges related to being a caregiver. EMBRACE was found to support and strengthen the participants in gaining more control in everyday life, creating a sense of coherence. Through targeted videos and discussions with peers, the participants felt prepared for the illness trajectory of their relative. Peer support promoted resilient functioning and reduced their feelings of loneliness. Clinical trial registration: This study was registered on clinicaltrials.gov under the name: A Complex Intervention Study on a Palliative Rehabilitation Blended Learning Programme to Support Relatives and Health Care Providers of People with ALS and Cognitive Impairments in Coping with Challenges. ID no. NCT04638608. URL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT04638608&cntry=&state=&city=&dist=.

A patienthood that transcends the patient: An analysis of patient research partners' narratives of involvement in a Canadian arthritis patient advisory board.

OBJECTIVES: Incorporating the perspectives of patients and public into the conduct of research has the potential to make scientific research more democratic. This paper explores how being a patient partner on an arthritis patient advisory board shapes the patienthood of a person living with arthritis. METHODS: An analysis was undertaken of the narratives of 22 patient research partners interviewed about their experiences on the Arthritis Patient Advisory Board (APAB), based in Vancouver, Canada. RESULTS: Participants' motivations to become involved in APAB stemmed largely from their desire to change their relationship with their condition. APAB was a living collective project in which participants invested their hope, both for their own lives as patients and for others with the disease. CONCLUSIONS: Our findings highlight how the journeys of patient partners connect and integrate seemingly disparate conceptions of what it means to be a patient. One's experience as a clinical 'patient' transforms into the broader notion of civic patienthood.

Exploring Mistreatment of Medical Students by Patients: A Qualitative Study.

PURPOSE: Mistreatment of medical students by patients has not been qualitatively explored in the literature. The authors sought to develop a rich understanding of the impact and consequences of medical students' experiences of mistreatment by patients. METHOD: This exploratory descriptive qualitative study was conducted at a large Canadian medical school from April-November 2020. Fourteen medical students were recruited for semistructured interviews. Students were asked about their experiences of mistreatment by patients and how they responded to these experiences. Transcripts were thematically analyzed using an inductive approach, and the authors interwove critical theory into their conceptual interpretation of the data. RESULTS: Fourteen medical students (median age = 25.5; 10, 71.4% self-reported male; 12, 85.7% self-identified visible minority) participated in this study. Twelve (85.7%) participants had personally experienced patient mistreatment and 2 (14.3%) had witnessed mistreatment of another learner. Medical students described being mistreated by patients based on their gender and race/ethnicity. Although all participants were aware of the institution's official mechanism for reporting mistreatment, none filed an official report. Some participants described turning to their formal (faculty members and residents) and informal (family and friends) social supports to cope with mistreatment by patients. Participants described resenting and avoiding patients who mistreated them and struggling to maintain empathy for, openness to, and overall ethical engagement with discriminatory patients. Students often described a need to be stoic toward their experiences of mistreatment by patients, often seeing it as their "professional duty" to overcome and thus suppress the negative emotions associated with mistreatment. CONCLUSIONS: Medical schools must proactively develop multifaceted mechanisms to support medical students who experience mistreatment by patients. Future research can further uncover this neglected dimension of the hidden curriculum to better develop responses to incidents of mistreatment that commit to antiracism, antisexism, patient care, and learner care.

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.

Perceived eHealth literacy and health literacy among people with spinal cord injury: A cross-sectional study.

OBJECTIVES: This purpose of this research was to (1) to evaluate eHealth and general health literacy levels among individuals with spinal cord injury (SCI) and (2) to identify relationships between eHealth literacy, general health literacy, and various sociodemographic factors. DESIGN: Cross-sectional. SETTING: The study was conducted in the community setting. PARTICIPANTS: As part of a larger study, a total of 50 community-dwelling individuals with SCI were recruited. INTERVENTIONS: n/a. OUTCOME MEASURES: Quantitative online survey data were collected on participants' sociodemographic characteristics, eHealth literacy (using the eHealth Literacy Scale), general health literacy (using the Brief Health Literacy Screening Tool). RESULTS: The average age of participants was 49 years old; 25 participants were male and 25 were female. A total of 39 participants experienced traumatic SCI and 11 participants experienced non-traumatic SCI. Participants demonstrated moderate levels of eHealth literacy (31.6 out of 40) and general health literacy (17.6 out of 20). A significant, positive correlation was found between eHealth literacy and general health literacy. Significant, positive correlations were found between general health literacy and sociodemographic factors, including income and education. A significant, negative correlation was found between general health literacy and time since injury. CONCLUSION: No previous studies we are aware of have evaluated perceived eHealth literacy and general health literacy among people with SCI. This study demonstrated the diverse range of eHealth literacy levels in SCI populations and how this, and other factors, may impact an individual's ability to self-manage and adopt to eHealth technologies.

Beyond dyadic communication: Network of communication in inflammatory arthritis teams.

OBJECTIVE: To explore how communication is perceived and care is negotiated amongst IA healthcare teams by drawing on the perspectives of each team member. METHOD: This analysis drew on data from an ongoing three-year study exploring team-based IA care. We interviewed 11 participants including two men with IA and their family care providers and healthcare providers. We used a three-staged analytic process and integrated broad tenets of social network theory to understand the relational dimensions of team members experiences. RESULT: Analysis revealed three themes regarding communication and care: (1) seeking/sharing information, (2) striving to coordinate unified care, and (3) providing patients a voice. DISCUSSION: This study emphasizes the importance of understanding team dynamics beyond the dyad of patient and care provider. Negotiating power and decision-making in IA care is a dynamic process involving shifting levels of responsibility amongst a care team. Communication-based strategies that extend dyadic interactions may enhance teamwork and health outcomes in chronic conditions.

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.

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.

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.

Exploring how immigrant international medical graduates successfully manage complex sociocultural challenges.

Background: While immigrant international medical graduates (I-IMGs) contribute significantly to the physician workforce in North America, researchers have highlighted the myriad of ways sociocultural challenges can negatively impact their success. Conceptual understanding that unpacks the complex processes of how I-IMGs effectively manage sociocultural challenges is relatively sparse. In addressing this critical knowledge gap, this study explored how I-IMGs successfully manage sociocultural differences as postgraduate residents. Methods: We interviewed eleven I-IMGs from diverse backgrounds who are in training or recently trained in a distributed multi-site postgraduate medical training program in Canada. We used the lens of sociocultural learning theory to gain insights into the processes of how I-IMGs describe successful management of sociocultural challenges. Results: The overarching storyline of participants emphasized that their experiences were humbling as they grappled with inner struggles, emotions, and vulnerabilities while embracing the ambiguity of not knowing what was expected of them. The following dominant themes from their narratives encapsulate the salient processes for how I-IMGs conceptualize and successfully manage sociocultural challenges: 1) successfully navigating transitions; 2) resisting or altering elements of prior sociocultural norms while embracing the new; 3) living and being in community and having supportive social networks; 4) risk taking to self-advocate and actively seek help. Conclusion: Understanding the strengths and positive strategies for how I-IMGs interface with complex sociocultural challenges has application for medical training institutions. Our insights suggest the need for practical, effective, and continuous assistance within I-IMG training programs to better support future trainees dealing with sociocultural challenges.

Contexte: Alors que les diplômés internationaux en médecine immigrants (DIMI) contribuent de manière significative à la main-d'œuvre médicale en Amérique du Nord, des travaux ont mis en évidence le fait que des défis socioculturels peuvent de manières diverses entraver leur réussite. Les processus complexes par lesquels les DIMI réussissent à affronter les défis socioculturels sont peu compris sur le plan conceptuel. Pour combler cette importante lacune, la présente étude a exploré les façons dont les DIMI affrontent avec succès les différences socioculturelles pendant leur résidence. Méthodes: Nous avons interrogé onze médecins résidents étrangers d'origines diverses qui suivent ou qui ont récemment suivi une formation dans le cadre d'un programme de résidence multi-sites au Canada. Nous nous sommes basés sur la théorie socioculturelle de l'apprentissage pour mieux comprendre les processus employés par les DIMI pour faire face efficacement aux défis socioculturels. Résultats: Le récit dominant des participants est d'être aux prises avec des luttes intérieures, des émotions et des vulnérabilités, sans savoir ce que l'on attendait d'eux, une leçon d'humilité. Les thèmes principaux qui en ressortent et qui résument la manière dont les DIMI conceptualisent et gèrent avec succès les défis socioculturels sont les suivants : 1) réussir les transitions ; 2) résister ou revoir des éléments des normes socioculturelles qu'ils respectaient par le passé tout en adoptant de nouvelles normes; 3) participer à la vie de la collectivité et avoir des réseaux sociaux de soutien ; 4) prendre le risque de se faire entendre et de chercher activement de l'aide. Conclusion: Comprendre les points forts et les stratégies positives employées par les DIMI pour faire face aux défis socioculturels complexes serait fort utile pour les établissements d'enseignement médical. Nos observations plaident en faveur de la mise en place d'une assistance pratique, efficace et continue dans les programmes de formation pour mieux soutenir les futurs DIMI confrontés à des défis socioculturels.

The ways social networks shape reflection on early significant clinical experiences in medical school.

Background: Medical curricula are increasingly providing opportunities to guide reflection for medical students. However, educational approaches are often limited to formalized classroom initiatives where reflection is prescriptive and measurable. There is paucity of literature that explores the personal ways students may experience authentic reflection outside of curricular time. The purpose of this study was to understand how social networks might shape dimensions of reflection. Methods: This study employed a qualitative social network analysis approach with a core sample of seven first year undergraduate medical students who described their relationships with 61 individuals in their networks. Data consisted of participant generated sociograms and individual semi-structured interviews. Results: Many learners struggled to find significant ways to involve their social networks outside of medicine in their new educational experiences. It appeared that some medical students began in-grouping, becoming more socially exclusive. Interestingly, participants emphasized how curricular opportunities such as reflective portfolio sessions were useful for capturing a diversity of perspectives. Conclusions: Our study is one of the first to characterize the social networks inside and outside of medical school that students utilize to discuss and reflect on early significant clinical experiences. Recent commentary in the literature has suggested reflection is diverse and personal in nature and our study offers empirical evidence to demonstrate this. Our insights emphasize the importance of moving from an instrumental approach to an authentic socially situated approach if we wish to cultivate reflective lifelong learning.

Contexte: Les cursus d'études en médecine offrent de plus en plus d'occasions de guider la réflexion des étudiants. Cependant, les approches pédagogiques se limitent souvent à des initiatives formelles en classe où la réflexion est obligatoire et évaluée. Il y a peu d'études scientifiques sur la réflexion personnelle et authentique des étudiants en dehors des cours. Cet article vise à explorer comment les réseaux sociaux peuvent façonner des dimensions de la réflexion. Méthodes: Cette étude est fondée sur une approche qualitative d'analyse des réseaux sociaux avec un échantillon de base de sept étudiants en première année de médecine qui ont décrit leurs relations avec 61 personnes issues de leurs réseaux. Les données sont constituées de sociogrammes créés par les participants et d'entretiens individuels semi-structurés. Résultats: De nombreux apprenants ont eu du mal à trouver une manière de partager leurs nouvelles expériences éducatives de façon significative avec leurs réseaux sociaux extérieurs à la médecine. Le fait que les participants soulignent l'utilité des occasions qu'offre leur programme, comme les séances de réflexion sur le portfolio, pour accéder à une diversité de perspectives est également intéressant à noter. Conclusions: Notre étude est l'une des premières à analyser l'utilisation que font les étudiants en médecine de réseaux sociaux tant l'intérieur qu'à l'extérieur de la faculté pour soutenir leur réflexion sur leurs premières expériences cliniques importantes et pour en discuter. Des publications scientifiques récentes suggèrent que ces réflexions sont personnelles et diversifiées et notre étude en apporte la preuve empirique. Nos observations soulignent l'importance de passer d'une approche instrumentale à une approche authentique et socialement située si nous souhaitons cultiver un apprentissage réflexif tout au long de la vie.

Barriers and Facilitators to eHealth Technology Use Among Community-Dwelling Individuals With Spinal Cord Injury: A Qualitative Study.

Background: As eHealth technologies become a more prevalent means to access care and self-manage health, it is important to identify the unique facilitators and barriers to their use. Few studies have evaluated the use or potential use of eHealth technologies in spinal cord injury (SCI) populations. Objectives: The primary objective of this study was to explore and identify barriers and facilitators to engagement with eHealth technologies among individuals with SCI. Methods: A qualitative descriptive study was conducted. Data were collected via one-on-one, semi-structured interviews with a subsample of 20 community-dwelling participants enrolled in a larger clinical trial. Analysis of the transcripts was undertaken using a four-phase process of content analysis. Results: Our analysis identified three barriers to engagement with eHealth technologies, including (1) overcoming a digital divide to comprehending and utilizing eHealth technologies, (2) navigating internet resources that provide too much information, and (3) interacting with these technologies despite having limited hand function. Our analysis also identified three facilitators to using eHealth technologies, including (1) having previous successful experiences with eHealth technologies, (2) being able to use voice activation features, and (3) being able to interact in an online community network. Conclusion: By exploring barriers and facilitators to eHealth technology use, these findings may have a short-term impact on informing researchers and clinicians on important factors affecting engagement of individuals with SCI with telemedicine, mobile, and web applications (apps) and a long-term impact on informing future development of eHealth interventions and tools among chronic disease populations.

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.