Storylines of family medicine XI: professional identity formation-nurturing one's own story.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XI: professional identity formation-nurturing one's own story', authors address the following themes: 'The social construction of professional identity', 'On becoming a family physician', 'What's on the test?-professionalism for family physicians', 'The ugly doc-ling', 'Teachers-the essence of who we are', 'Family medicine research-it starts in the clinic', 'Socially accountability in medical education', 'Personal philosophy and how to find it' and 'Teaching and learning with Storylines of Family Medicine'. May these essays encourage readers to find their own creative spark in medicine.

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.

Emerging models for successful treatment of complex regional pain syndrome in children and young adults.

Complex regional pain syndrome (CRPS) is a relatively common condition that is often not well recognised or treated adequately. Patients are usually referred to multidisciplinary pain services, but outcomes remain variable. This case report describes a recent patient with CRPS who was treated quickly and effectively through a simple explanation of the relationship between mind and body, and who then was able to modify her own thought processes and behaviours. This single intervention enabled a complete resolution of symptoms. This report illustrates the clinical application of recent insights into neuroplasticity and individually tailored patient self-management that may now offer successful treatment of an otherwise chronic and disabling condition, especially in younger patients. There are implications for doctors in current practice, as well as for the training of medical students and junior doctors.

Challenges in the doctor-patient relationship: 12 tips for more effective peer group discussion.

In New Zealand, almost all general practitioners are members of peer groups, which provide opportunities for both clinical discussion and collegial support. This article proposes that peer groups can also be a useful medium for exploring specific challenges within the doctor-patient relationship. However, the peer group culture needs to be receptive to this particular goal. Structured discussion can help peer group members explore interpersonal issues more thoroughly.

Republished original viewpoint: complaints, shame and defensive medicine.

While the complaints process is intended to improve healthcare, some doctors appear to practise defensive medicine after receiving a complaint. This response occurs in countries that use a tort-based medicolegal system as well as in countries with less professional liability. Defensive medicine is based on avoiding malpractice liability rather than considering a risk-benefit analysis for both investigations and treatment. There is also evidence that this style of practice is low quality in terms of decision-making, cost and patient outcomes. Western medical practice is based on biomedicine: determining medical failure using the underlying, taken-for-granted assumptions of biomedicine can potentially contribute to a response of shame after an adverse outcome or a complaint. Shame is implicated in the observable changes in practising behaviour after receipt of a complaint. Identifying and responding to shame is required if doctors are to respond to a complaint with an overall improvement in clinical practice. This will eventually improve the outcomes of the complaints process.

Complaints, shame and defensive medicine.

While the complaints process is intended to improve healthcare, some doctors appear to practise defensive medicine after receiving a complaint. This response occurs in countries that use a tort-based medicolegal system as well as in countries with less professional liability. Defensive medicine is based on avoiding malpractice liability rather than considering a risk-benefit analysis for both investigations and treatment. There is also evidence that this style of practice is low quality in terms of decision-making, cost and patient outcomes. Western medical practice is based on biomedicine: determining medical failure using the underlying, taken-for-granted assumptions of biomedicine can potentially contribute to a response of shame after an adverse outcome or a complaint. Shame is implicated in the observable changes in practising behaviour after receipt of a complaint. Identifying and responding to shame is required if doctors are to respond to a complaint with an overall improvement in clinical practice. This will eventually improve the outcomes of the complaints process.

Role modeling the doctor-patient relationship in the clinical curriculum.

BACKGROUND AND OBJECTIVES: Training in relationship skills relies heavily on role modeling: students observing clinicians at work. This study explored student and faculty perceptions of student learning about relationship skills in hospital and ambulatory settings. METHODS: Qualitative data from focus groups and long interviews were coded by the authors through an iterative dialogic process. Participants were 15 faculty and 35 medical students in clinical training in a New Zealand medical school. RESULTS: Teaching of doctor-patient relationship skills was highly variable, rarely explicit, and heavily dependent on role modeling. Students noted variable focus on relational skills between rotations, incongruity between preclinical training and the behaviors observed in clinical environments, and a need to discern which relational skills were facilitative. Role models who transparently shared their personal experiences of doctoring were more effective in helping students learn relationship skills. CONCLUSIONS: Role modeling alone is insufficient for helping students acquire exemplary doctor-patient relationship skills. Role models must explicitly reflect upon the complex intricacies of interacting with patients to help students understand and incorporate specific skills. Lack of transparency is a barrier to quality role modeling that may be mitigated in ambulatory, primary care settings.

In search of professionalism: implications for medical education.

This is the seventh article in an education series, discussing some of the 'hot topics' in teaching and learning in medicine. Historically, 'professionalism' was defined by the social structures of medicine, but has moved on to represent the expected behaviours and attributes of practitioners. Well publicised cases of professional misconduct, the rise of medical ethics as a discipline, and the move to a more patient-centred approach have driven the profile of professionalism into mainstream medical education. While there are many definitions of medical professionalism, there is a growing degree of consensus around what it encompasses; the way we manage tasks, our interactions with others, and looking after ourselves. The literature indicates that professionalism can be taught, learnt and applied; that attributes and behaviours can be identified; and that assessment is best approached using a range of methods over time. For learners, one of the critical factors in developing professionalism is the modelling by senior members of the profession as students move from peripheral observers to legitimate participants. Medical programmes in New Zealand are engaging with this literature in developing current curricula.

Faculty and medical students' perceptions of teaching and learning about the doctor-patient relationship.

OBJECTIVE: To explore student and faculty perceptions of how students are learning doctor-patient relationship skills in their clinical medical education. METHODS: Exploratory qualitative study involving data from interviews and focus groups with students and interviews with teaching faculty. RESULTS: Respondents reported that pre-clinical relationship skills curricula were not well-coordinated with clinical curricula. Within the clinical curriculum, respondents perceived a disparity between general practice and hospital-based attachments. Teaching of relationship skills on the wards was highly variable, rarely explicit, and primarily dependent on role-modelling. In contrast, general practice runs included explicit teaching with feedback that reinforced skills taught in the pre-clinical curriculum. Respondents recommended increased focus on and assessment of students' interpersonal skills within clinical settings. CONCLUSION: Pre-clinical and clinical relationship skills curricula were not coordinated. The tension between service commitments and student teaching in hospital-based attachments contributed to an insufficient focus on communication and relationship skills acquisition and did not reinforce teaching in pre-clinical and ambulatory clinical settings. PRACTICE IMPLICATIONS: The teaching of doctor-patient relationship skills can be augmented by coordinating pre-clinical and clinical curricula and by requiring observation and structured feedback related to explicit criteria of student skills acquisition across all clinical learning experiences.

The revised 'Early Learning in Medicine' curriculum at the University of Otago--focusing on students, patients, and community.

This article describes recent changes to years 2 and 3 of undergraduate medical education at the University of Otago, now termed 'Early Learning in Medicine'. These changes focus on learning that is contextually relevant, student centred, horizontally and vertically integrated, and community based. Three new programmes have been introduced to the course; Integrated Cases, Clinical Skills, and Healthcare in the Community. Innovative teaching and learning activities have been implemented to prepare students for a greater level of interaction with patients, carers, health professionals, and community organisations. This curriculum also aims to increase the relevance of their theoretical learning within and across years, and foster an early appreciation of professional responsibilities. Challenges to facilitating this direction are described and framed by an evolutionary approach that builds upon the strong features of the previous course.

Co-locating primary care facilities within emergency departments: brilliant innovation or unwelcome intervention into clinical care?

The management of a regional hospital in New Zealand is proposing to co-locate a primary care facility within the local emergency department (ED). This article reviews the reasons for this proposal which include overcrowding of ED, so-called 'inappropriate' attendees, and provision of 24-hour primary medical services for Dunedin City. While the proposal seems to have some intuitive merit, the attribution of overcrowding in ED to attendance by GP-type patients is simplistic; it does not address how patients are processed within ED or how they are transferred to wards later if required ('access block'). This article also discusses some other unresolved issues including the implications of recent funding arrangements in primary care and risk management.