Identity construction in medical student stories about experiences of disgust in early nursing home placements: a dialogical narrative analysis.

OBJECTIVES: To explore medical students' reflective essays about encounters with residents during preclinical nursing home placements. DESIGN: Dialogical narrative analysis aiming at how students characterise residents and construct identities in relation to them. SETTING: Medical students' professional identity construction through storytelling has been demonstrated in contexts including hospitals and nursing homes. Some preclinical students participate in nursing home placements, caring for residents, many living with dementia. Students' interactions with these residents can expose them to uncontained body fluids or disturbing behaviour, evoking feelings of disgust or fear. PARTICIPANTS: Reflective essays about experiences as caregivers in nursing homes submitted to a writing competition by preclinical medical students in New Zealand. RESULTS: Describing early encounters, students characterised residents as passive or alien, and themselves as vulnerable and dependent. After providing care for residents, they identified them as individuals and themselves as responsible caregivers. However, in stories of later encounters that evoked disgust, some students again identified themselves as overwhelmed and vulnerable, and residents as problems or passive objects. We used Kristeva's concept of abjection to explore this phenomenon and its relationship with identity construction. CONCLUSIONS: Providing personal care can help students identify residents as individuals and themselves as responsible caregivers. Experiencing disgust in response to corporeal or psychic boundary violations can lead to abjection and loss of empathy. Awareness of this possibility may increase students' capacity to treat people with dignity and compassion, even when they evoke fear or disgust. Medical education theory and practice should acknowledge and address the potential impact of strong negative emotions experienced by medical students during clinical encounters.

Experience-based learning: junior medical students' reflections on end-of-life care.

CONTEXT: Experience-based learning may contribute to confidence, competence and professional identity; early experiences may be particularly formative. This study explored how pre-clinical students make sense of their participation in the provision of end-of-life care within community settings. METHODS: We performed dialogic narrative analysis on essays written by junior medical students in New Zealand. Students had reflected on their participation as assistant caregivers in nursing homes, contributing to the personal care of the elderly residents who lived there. Essays had been submitted to a reflective writing competition that was run separately from the students' medical studies. We analysed five essays about nursing placements, focusing on students' stories about their engagement with residents who were suffering or were receiving end-of-life care. RESULTS: In their essays, students wrote about powerful and at times intense learning experiences during these early clinical attachments; their attitudes to death and dying were both highlighted and changed. Allied health professionals (e.g. caregivers) provided important support for student learning, especially in relation to seminal encounters such as those occurring in the course of providing end-of-life care. Support increased students' participation and confidence. Reflective writing helped students make sense of their learning and led them to think about their own professional identities, even in the absence of observing or working with doctors in those settings. CONCLUSIONS: Students' reflections revealed that they tend to filter their learning experiences through the lens of future doctoring, especially when involved in challenging clinical situations. Although medical schools have limited influence on interprofessional relationships or mentoring within the environment of community hospitals, support from other staff can help junior students make the most of their engagement in end-of-life care. In-depth reflection may facilitate the links between experience-based learning and students' emerging ideas about their own professional identities, but the underlying mechanisms need further exploration.

Medical student stories of participation in patient care-related activities: the construction of relational identity.

Professional identity formation is acknowledged as one of the fundamental tasks of contemporary medical education. Identity is a social phenomenon, constructed through participation in everyday activities and an integral part of every learning interaction. In this paper we report from an Australian ethnographic study into how medical students and patients use narrative to construct their identities. The dialogic narrative analysis employed focused on the production of meaning through the use of language devices in a given context, and the juxtaposition of multiple perspectives. Two stories told by students about their participation in patient care-related activities reveal how identities are constructed in this context through depictions of the relationships between medical students, patients and clinical teachers. These students use the rhetorical functions of stories to characterise doctors and patients in certain ways, and position themselves in relation to them. They defend common practices that circumvent valid consent processes, justified by the imperative to maximise students' participation in patient care-related activities. In doing so, they identify patients as their adversaries, and doctors as allies. Both students are influenced by others' expectations but one reveals the active nature of identity work, describing subtle acts of resistance. These stories illustrate how practices for securing students' access to patients can influence students' emerging identities, with implications for their future disclosure and consent practices. We argue that more collaborative ways of involving medical students in patient care-related activities will be facilitated if students and clinical teachers develop insight into the relational nature of identity work.

The role of emotions in health professional ethics teaching.

In this paper, we put forward the view that emotions have a legitimate and important role in health professional ethics education. This paper draws upon our experience of running a narrative ethics education programme for ethics educators from a range of healthcare disciplines. It describes the way in which emotions may be elicited in narrative ethics teaching and considers the appropriate role of emotions in ethics education for health professionals. We argue there is a need for a pedagogical framework to productively incorporate the role of emotions in health professional ethics teaching. We suggest a theoretical basis for an ethics pedagogy that integrates health professional emotions in both the experience and the analysis of ethical practice, and identify a range of strategies to support the educator to incorporate emotion within their ethics teaching.

Assessing the predictive value of HIV indicator conditions in general practice: a case-control study using the THIN database.

BACKGROUND: UK HIV guidelines identify 37 clinical indicator conditions for adult HIV infection that should prompt an HIV test. However, few data currently exist to show their predictive value in identifying undiagnosed HIV. AIM: To identify symptoms and clinical diagnoses associated with HIV infection and assess their relative importance in identifying HIV cases, using data from The Health Improvement Network (THIN) general practice database. DESIGN AND SETTING: A case-control study in primary care. METHOD: Cases (HIV-positive patients) were matched to controls (not known to have HIV). Data from 939 cases and 2576 controls were included (n = 3515). Statistical analysis assessed the incidence of the 37 clinical conditions in cases and controls, and their predictive value in indicating HIV infection, and derived odds ratios (ORs) for each indicator condition. RESULTS: Twelve indicator conditions were significantly associated with HIV infection; 74.2% of HIV cases (n = 697) presented with none of the HIV indicator conditions prior to diagnosis. The conditions most strongly associated with HIV infection were bacterial pneumonia (OR = 47.7; 95% confidence interval [CI] = 5.6 to 404.2) and oral candidiasis (OR = 29.4; 95% CI = 6.9 to 125.5). The signs and symptoms most associated with HIV were weight loss (OR = 13.4; 95% CI = 5.0 to 36.0), pyrexia of unknown origin (OR = 7.2; 95% CI = 2.8 to 18.7), and diarrhoea (one or two consultations). CONCLUSION: This is the first study to quantify the predictive value of clinical diagnoses related to HIV infection in primary care. In identifying the conditions most strongly associated with HIV, this study could aid GPs in offering targeted HIV testing to those at highest risk.

Practising engagement: Infusing communication with empathy and compassion in medical students' clinical encounters.

Patients commonly experience some physicians' ways of interacting with them as detached and indicating a lack of concern for their welfare. This is likely to add to the distress experienced by a person seeking healing, as well as interfering with the exchange of information required for good medical care. Despite contemporary medical schools' focus on clinical communication, and on training for 'patient-centred' practice, problems with the relations between doctors and patients are still widely acknowledged. The importance of demonstrating empathy, compassion and caring has been highlighted in the literature. In this article I draw on a clinical narrative to elucidate my interpretation of engagement, which entails practices of attentiveness, respectful dialogue and commitment. I propose that practising engagement may help medical students and doctors to infuse their clinical encounters with empathy and compassion, with the aim of providing care that is experienced as being more humane. This practice has the potential to contribute to innovative pedagogical approaches to clinical communication.

The prevalence of erectile dysfunction in post-treatment colorectal cancer patients and their interests in seeking treatment: a cross-sectional survey in the west-midlands.

INTRODUCTION: Erectile dysfunction (ED) is a recognized complication of colorectal cancer treatment, particularly if surgery is below the recto-sigmoid junction (RSJ), and is an important quality-of-life issue. Previous studies have generated inconsistent prevalence estimates. AIM: We aimed to establish the prevalence of ED in postsurgery colorectal cancer patients and to establish what proportion wished to seek treatment. MAIN OUTCOME MEASURES: Questionnaire: sociodemographics, treatment methods, International Index of Erectile Function (IIEF)-5 questionnaire (validated tool to assess erectile function): score of <21 being used to define ED. METHODS: Cross-sectional survey. INCLUSION CRITERIA: adult male colorectal cancer patients diagnosed in 2000-2007, treated with curative intent in one teaching hospital. STATISTICAL ANALYSIS: logistic regression analysis to determine predictors of ED. RESULTS: The response rate was 46% (229/499). Respondents were aged 28 to 95 years; the majority were white (93.9%), more than half (57.1%) were in a sexual relationship, only a third reported having sex in the past 6 months (33.3%). The vast majority (75.1%; 172/229) of responders had ED as defined by the IIEF-5. ED was significantly associated with increasing age (P < 0.0005), having a malignancy below the RSJ (P = 0.002), having previous radiotherapy (P = 0.007), and having a stoma (P = 0.014). Those with ED were less likely to be in a sexual relationship (P = 0.002) and less likely to have had sex in the last 6 months (P < 0.0005). Only 29% of those with ED were not interested in treatment for their condition. CONCLUSIONS: These data suggest a prevalence rate of ED of 75% in colorectal cancer survivors; this may be functional or psychological in origin. Quality of life may be improved if follow-up clinics for cancer survivors not only concentrated on the detection of recurrence but also offered assessment of erectile function and referral for patients who desire treatment.

The use of herbal medicines by people with cancer: a qualitative study.

BACKGROUND: Between 7% and 48% of cancer patients report taking herbal medicines after diagnosis. Because of the possibility of unwanted side effects or interactions with conventional treatments, people with cancer are generally advised to tell the professionals treating them if they are taking any form of medication, including herbal medicines and supplements. Studies suggest that only about half do so and that the professionals themselves have at best very limited knowledge and feel unable to give informed advice. This study is intended to inform the future development of information resources for cancer patients, survivors and healthcare professionals including tools for use before or during consultation to make it easier for patients to mention, and for healthcare professionals to ask about, use of herbal medications. METHODS/DESIGN: This is a three-phase study. In phase 1, a systematic review of the literature on self-medication with herbal medicines among UK populations living with cancer will establish the current evidence base on use of herbal medicine, sources of information, characteristics and motivations. This will allow us to better understand what aspects need further investigation and inform the topic guide for a qualitative study (phase 2). Six focus groups of six to eight cancer patients who have used at least one herbal preparation since diagnosis will explore behaviour, beliefs, knowledge, information sources and needs in an informal conversational setting.Informed by the findings of the systematic review and qualitative study, in phase 3 we will construct and pilot a questionnaire for a future large-scale survey to quantify and prioritise people's beliefs, needs and information preferences. DISCUSSION: Despite known interactions with conventional cancer treatments and contraindications for some herbal remedies with specific cancers, reliable information resources for patients are very limited. Identifying cancer patients' information needs and preferences is the first step in creating a suitable resource for both the public and the professionals advising them.

A prospective study to assess the value of MMP-9 in improving the appropriateness of urgent referrals for colorectal cancer.

BACKGROUND: Bowel cancer is common and is a major cause of death. Most people with bowel symptoms who meet the criteria for urgent referral to secondary care will not be found to have bowel cancer, and some people who are found to have cancer will have been referred routinely rather than urgently. If general practitioners could better identify people who were likely to have bowel cancer or conditions that may lead to bowel cancer, the pressure on hospital clinics may be reduced, enabling these patients to be seen more quickly. Increased levels of an enzyme called matrix metalloproteinase 9 (MMP-9) have been found to be associated with such conditions, and this can be measured from a blood sample. This study aims to find out whether measuring MMP-9 levels could improve the appropriateness of urgent referrals for patients with bowel symptoms. METHODS: People aged 18 years or older referred to a colorectal clinic will be asked to complete a questionnaire about symptoms, recent injuries or chronic illnesses (these can increase the level of matrix metalloproteinases) and family history of bowel cancer. A blood sample will be taken from people who consent to take part to assess MMP-9 levels, and the results of examination at the clinic and/or investigations arising from the clinic visit will be collected from hospital records. The accuracy of MMP-9 will be assessed by comparing the MMP-9 level with the resulting diagnosis. The combination of factors (e.g. symptoms and MMP-9 level) that best predict a diagnosis of malignancy (invasive disease or polyps) will be determined. DISCUSSION: Although guidelines are in place to facilitate referrals to colorectal clinics, symptoms alone do not adequately distinguish people with malignancy from people with benign conditions. This study will establish whether MMP-9 could assist this process. If this were the case, measurement of MMP-9 levels could be used by general practitioners to assist in the identification of people who were most likely to have bowel cancer or conditions that may lead to bowel cancer, and who should, therefore, be referred most urgently to secondary care.