EXPLORING THE HIDDEN CURRICULUM: A qualitative analysis of medical students’ reflections on professionalism in surgical clerkship

KITTMER TPEMBERTON JHOOGENES J CAMERON BH

ASE March 22, 2012

MacSERGMcMaster Surgical Education

Research Group

Background I

Clerkship is a unique time in professional development

Professionalism curriculaFormal – Professional Competencies1

Informal – bedside teachingHidden2-4

1Risdon and Baptiste 2006, 2Stern and Papadakis 2006, 3Karnieli-Miller et al 2011, 4Hicks et al 2001

Background II

Reflective writing in clerkship• Effective5

• Implemented in various forms5-8

Qualitative professionalism research has been used to explore the hidden curriculum,7-9 but never with an explicit focus on surgical clerkship

5Hill-Sakurai et al 2008 6Wald and Reis 2010, 7Kaldjian et al 2011, 8Karnieli-Miller 2011, 9Hicks et al 2001

2001 2 3 4 5 6 7 8 9 20100

500

1000

1500

2000

2500

'Professionalism' on PubMed last decade

Professionalism + medical education+ surgery

nu

mb

er

of

pu

blica

tion

s

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

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

Methods II

64 reports available from class of 2009

39 early group 25 late group

Results

Clerk

Patient(14)

Team(6)

System(4)

Self(3)

27 themes in total

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

Patient

Team

System

Self

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

Patient

Team

System

Self

“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.”

Clerk-Patient II

Communication– Cultural Competency – Health Literacy – Breaking Bad News– The Difficult Patient – Disclosure of Adverse Event

Clerk

Patient

Team

System

Self

“When the words 'lymph nodes' were spoken, I

saw on the faces of the family members that they did not understand.”

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

Patient

Team

System

Self

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

Patient

Team

System

Self

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 discuss7

7Kaldjian et al 2011

Discussion II

Junior vs. senior clerks:Varying levels of clinical experience &

independenceThose wishing to match to surgery tend to

do core surgery early in clerkshipPossible burnout later in clerkship

Limitations

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

Future Directions

Addressing the hidden curriculum10-11

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 development5

New plans for a longitudinal professionalism curriculum in clerkship○ Modeled after surgical rotation ○ CIR/Case + small-group discussion

10Christian et al 2008, 11Busing et al, 5Hill-Sakurai et al 2008

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

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. <http://www.afmc.ca/future-of-medical-education-in-canada/medical-doctor-project/index.php>

• 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.