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E XPLORING THE HIDDEN CURRICULUM : A qualitative analysis of medical students’ reflections on professionalism in surgical clerkship K ITTMER T P EMBERTON.

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Presentation on theme: "E XPLORING THE HIDDEN CURRICULUM : A qualitative analysis of medical students’ reflections on professionalism in surgical clerkship K ITTMER T P EMBERTON."— Presentation transcript:

1 E XPLORING THE HIDDEN CURRICULUM : A qualitative analysis of medical students’ reflections on professionalism in surgical clerkship K ITTMER T P EMBERTON J H OOGENES J C AMERON BH ASE March 22, 2012

2 MacSERG McMaster Surgical Education Research Group

3 Background I  Clerkship is a unique time in professional development  Professionalism curricula Formal – Professional Competencies 1 Informal – bedside teaching Hidden 2-4 1 Risdon and Baptiste 2006, 2 Stern and Papadakis 2006, 3 Karnieli-Miller et al 2011, 4 Hicks et al 2001

4 Background II  Reflective writing in clerkship Effective 5 Implemented in various forms 5-8  Qualitative professionalism research has been used to explore the hidden curriculum, 7-9 but never with an explicit focus on surgical clerkship 5 Hill-Sakurai et al 2008 6 Wald and Reis 2010, 7 Kaldjian et al 2011, 8 Karnieli-Miller 2011, 9 Hicks et al 2001


6 Objectives  To identify and explore the main challenges in ethics and professionalism experienced by medical students during their surgical clerkship at McMaster as recorded in their critical incident reports (CIRs)  To assess for differences between junior and senior clerks’ CIR topics

7 Methods I Qualitative approach Divided CIRs into 2 groups: early and late 4 reviewers independently identified and then collaboratively determined emerging themes – Created codebook iteratively – Continued to conceptual saturation – Data reduction 2 reviewers re-read CIRs and recorded concept frequencies Validation – Data & investigator triangulation, audit trail, member-checking

8 Methods II 64 reports available from class of 2009 39 early group 25 late group

9 Results Clerk Patient(14) Team(6) System(4) Self(3) 27 themes in total

10 Clerk-Self "Frustration, exhaustion, helplessness were only some of the emotions present in the room as we went through a six hour procedure, our last chance to make a difference, but considered by all to be most likely a futile endeavour to save the patient's life."  Stress & emotions  Resolving ambiguity  Responding to patient suffering Clerk PatientTeamSystemSelf

11 Clerk-Patient I  Ethical Decision-Making – Patient Dignity – Patient Confidentiality – Patient-Centred Care – Provider bias – Do Not Resuscitate (DNR) & Code status – End of life issues – Informed consent (decision making) – Substitute Decision-Maker (decision making) – Patient autonomy Clerk PatientTeamSystemSelf

12 “Reacting to stressful situations by revealing your frustration can only contribute to the patient's anxiety and possible apprehension, and I believe in this case his humiliation - if I had been in his position, I would have felt like I was burdening the team with my unfortunate problem.”

13 Clerk-Patient II  Communication – Cultural Competency – Health Literacy – Breaking Bad News – The Difficult Patient – Disclosure of Adverse Event Clerk PatientTeamSystemSelf “When the words 'lymph nodes' were spoken, I saw on the faces of the family members that they did not understand.”

14 Clerk-Team  Clerk-Team – Team communication – Level of responsibility – Hierarchy – Interprofessional communication – Barriers to learning – Bullying “[Verbal abuse] also interferes with our ability to learn [...] I have overheard several clerks state that they simply don't want to be in the OR anymore as it isn't worth the abuse.” Clerk PatientTeamSystemSelf

15 Clerk-System  Clerk-System – Patient advocacy – Safety – Healthcare resource management – Medical error “I thought about hospital environment a few days ago. I believe that our patients (especially in surgery) suffer enough from their diseases. They came to us looking for help and relief. And it is our job to make the hospital environment safe for our patients.” Clerk PatientTeamSystemSelf

16 Discussion I  Professionalism curriculum well-received Positive feedback in clerks’ exit surveys  Communication and self-care were most frequent themes Learned with practice and experience Not always modeled well  Negative CIRs more common Assignment wording bias: “challenges” Previous research suggests assignment wording influences types of issues students discuss 7 7 Kaldjian et al 2011

17 Discussion II  Junior vs. senior clerks: Varying levels of clinical experience & independence Those wishing to match to surgery tend to do core surgery early in clerkship Possible burnout later in clerkship  Limitations

18 Conclusions CIRs are a rich source of information Clerks face diverse challenges in their interactions with self, patients, their team and the healthcare system Junior and senior clerks may have different educational needs Clerks are sensitive to the examples of professionalism they see every day Clerk Patient Team System Self

19 Future Directions  Addressing the hidden curriculum 10-11 Spreading the information to staff surgeons, residents, curriculum planners ○ What clerks struggle with most ○ What we can do better ○ Enhance teaching of CanMEDS competencies  Curriculum development 5 New plans for a longitudinal professionalism curriculum in clerkship ○ Modeled after surgical rotation ○ CIR/Case + small-group discussion 10 Christian et al 2008, 11 Busing et al, 5 Hill-Sakurai et al 2008

20 Acknowledgments  Small Group Facilitators  Class of 2009 clerks at the Michael G. DeGroote School of Medicine  Funding McMaster Surgical Associates McMaster Pediatric Surgery Research Collaborative

21 References Branch W, Pels RJ, Lawrence RS, Arky R. “Becoming a doctor: Critical-Incident reports from third-year medical students.” NEJM. Oct 1993: 1130-2. Busing N et al. “Recommendation V: Address the Hidden Curriculum.” The Future of Medical Education in Canada: A collective vision for MD education. Associations of Faculties of Medicine of Canada Website, 2010. Christian F, Pitt DF, Bond J, Davison P, Gomes A. “Professionalism – connecting the past and the present and a blueprint for the Canadian Association of General Surgeons.” Canadian Journal of Surgery. Hafferty FW. “Beyond curriculum reform: confronting medicine's hidden curriculum.” Academic Medicine. 2008;73(4):403-7. Hill-Sakurai LE, Lee CA, Schickedanz A, Maa J and Lai CJ. “A professional development course for the clinical clerkships: developing a student-centered curriculum.” J Gen Intern Med 23(7):964-8. Kaldjian LC, Rosenbaum, ME,Shinkunas LA, Woodhead JC,Antes LM, Rowat JA,Forman-offman VL. “Through students’ eyes: ethical and professional issues identified by third-year medical students during clerkships.” J Med Ethics 2011. Lempp H, Seale C. “The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching.” BMJ. 2004 Oct 2;329(7469):770-3. Reisman AB. “Outing the Hidden Curriculum.” The Hastings Center Report. 2006;36(4):9. Risdon C and Baptiste S. “Evaluating pre-clerkship professionalism in longitudinal small groups.” Medical Education 2006. 40: 1130-1. Wald HS and Reis SP. “Beyond the margins: reflective writing and development of reflective capacity in medical education.” J Gen Intern Med 25(7):746-9.

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