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“It’s just a clash of cultures”: emotional talk within medical students’ narratives of professionalism dilemmas

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Abstract

Recent investigations into the UK National Health Service revealed doctors’ failures to act with compassion and professionalism towards patients. The British media asked questions about what happens to students during their learning that influences such behaviour as doctors. We listened to 200 medical students’ narratives of professionalism dilemmas during workplace learning (n = 833) to understand the range of dilemmas experienced and emotional reactions to them. 32 group and 22 individual interviews were held across three medical schools (England, Wales, Australia). Data were analysed thematically (Framework Analysis), for negative emotional content (Linguistic Inquiry and Word Count) and a narrative analysis of one exemplar narrative was also conducted. While a wider range of professionalism dilemmas than previously identified were found, most were classified to five main sub-themes. Within these sub-themes, clinical students’ narratives contained more negative emotion words than pre-clinical students’ narratives (p = 0.046, r = −0.36). Narratives of ‘patient safety and dignity breaches by students’ contained fewer anger words (p = 0.003, r = −0.51), ‘patient safety and dignity breaches by healthcare professionals’ contained more anger words (p = 0.042, r = −0.37), ‘identity’ narratives contained fewer anxiety words (p = 0.034, r = 0.38), and ‘abuse’ narratives contained more sadness words (p = 0.013, r = −0.47). The narrative analysis revealed a complex interplay between identities, attribution of blame, narrated emotions and emotional residue. Analysing emotional talk within narratives suggests that medical students sometimes struggle with contradictory formal and informal learning experiences around professionalism arising from a cultural clash. We provide educational recommendations to facilitate students’ coping with their emotional reactions to professionalism dilemmas and to facilitate cultural change.

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Notes

  1. A pseudonym for anonymity.

References

  • Alpers, G. W., Winzelberg, A. J., Classen, C., Roberts, H., Dev, P., Koopman, C., et al. (2005). Evaluation of computerized text analysis in an internet breast cancer support group. Computers in Human Behavior, 21(2), 361–377.

    Article  Google Scholar 

  • Ayoko, O. B., Callan, V. J., & Härtel, C. E. J. (2003). Workplace conflict, bullying, and counterproductive behaviours. International Journal of Organizational Analysis, 11(4), 283–301.

    Article  Google Scholar 

  • Barclay, L. J., Skarlicki, D. P., & Pugh, S. D. (2005). Exploring the role of emotions in injustice perceptions and retaliation. Journal of Applied Psychology, 90(4), 629–643.

    Article  Google Scholar 

  • BBC News. (2011a). ‘Distressing stories’ of NHS care. Today. http://news.bbc.co.uk/today/hi/today/newsid_9397000/9397755.stm.

  • BBC News. (2011b). Care should not be a lottery. Today. http://news.bbc.co.uk/today/hi/today/newsid_9614000/9614255.stm.

  • Becker, H. S. (1970). Field work evidence. In Sociological work: Method and substance (pp. 39–62). New Brunswick, NJ: Transaction Books.

  • Bissonette, R., O’Shea, R. M., Horwitz, M., & Route, C. F. (1995). A data-generated basis for medical ethics education: categorizing issues experienced by students during clinical training. Academic Medicine, 70(11), 1035–1037.

    Article  Google Scholar 

  • Brotheridge, C. M., & Lee, R. T. (2010). Restless and confused: emotional responses to workplace bullying in men and women. Career Development International, 15(7), 687–707.

    Article  Google Scholar 

  • Caldicott, C. V., & Faber-Langendoen, K. (2005). Deception, discrimination and fear of reprisal: lessons in ethics from third year medical students. Academic Medicine, 80(9), 866–873.

    Article  Google Scholar 

  • Cassell, E. J. (2005). Medical ethics: consent or obedience? power and authority in medicine. New England Journal of Medicine, 352(4), 328–330.

    Article  Google Scholar 

  • Charon, R. (2006). Narrative medicine: honoring the stories of illness. New York: Oxford University Press.

    Google Scholar 

  • Christakis, D. A., & Feudtner, C. (1993). Ethics in a short white coat: the ethical dilemmas that medical students confront. Academic Medicine, 68(4), 249–254.

    Article  Google Scholar 

  • Cordingley, L., Hyde, C., Peters, S., Vernon, B., & Bundy, C. (2007). Undergraduate medical students’ exposure to clinical ethics: A challenge to the development of professional behaviours? Medical Education, 41(12), 1202–1209.

    Google Scholar 

  • Cruess, R. L., Cruess, S. R., & Steinert, Y. (Eds.). (2009). Teaching medical professionalism. Cambridge: Cambridge University Press.

    Google Scholar 

  • De Vogli, R., Ferrie, J. E., Chandola, T., Kivimaki, M., & Marmot, M. G. (2007). Unfairness and health: evidence from the Whitehall II study. Journal of Epidemiology and Community Health, 61(6), 513–518.

    Article  Google Scholar 

  • Department of Health. (2009). Reference guide to consent for examination or treatment, second edition 2009: Department of Health.

  • Donaldson, L. (2006). In Department of Health. (Ed.). Safety first: A report for patients, clinicians and healthcare managers. London: DH Publications.

  • Festinger, L. (1957). A theory of cognitive dissonance. Stanford, CA: Stanford University Press.

    Google Scholar 

  • Feudtner, C., Christakis, D., & Christakis, N. (1994). Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Academic Medicine, 69, 670–679.

    Article  Google Scholar 

  • General Medical Council. (2009). Tomorrow’s doctors retrieved 30th October 2009 from http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp.

  • General Medical Council and Medical Schools Council. (2007). Medical students: Professional behaviour and fitness to practise. Retrieved 10.10.08, from http://www.gmc-uk.org/students/.

  • Gergen, K. (2005). Narrative, moral identity and historical consciousness: A social constructionist account. In J. Straub (Ed.), Narration, identity and historical consciousness (pp. 99–119). New York: Bergham Books.

    Google Scholar 

  • Ginsburg, S. R., Kachan, N., & Lingard, L. (2005). Before the white coat: Perceptions of professional lapses in the pre-clerkship. Medical Education, 39(1), 12–19.

    Article  Google Scholar 

  • Ginsburg, S. R., & Lingard, L. (2011). ‘Is that normal?’ Pre-clerkship students’ approaches to professionalism dilemmas. Medical Education, 45(4), 362–371.

    Article  Google Scholar 

  • Ginsburg, S. R., Regehr, G., & Lingard, L. (2003). To be and not to be: The paradox of the emerging professional stance. Medical Education, 37(4), 350–357.

    Article  Google Scholar 

  • Ginsburg, S. R., Regehr, G., Stern, D., & Lingard, L. (2002). The anatomy of the professional lapse: Bridging the gap between traditional frameworks and students’ perceptions. Academic Medicine, 77(6), 516–522.

    Google Scholar 

  • Hanzel, I. (2011). Beyond Blumer and symbolic interactionism: The qualitative-quantitative issue in social theory and methodology. Philosophy of the Social Sciences, 41(3), 303–326.

    Article  Google Scholar 

  • Hicks, L. K., Lin, Y., Robertson, D. W., Robinson, D. L., & Woodrow, S. I. (2001). Understanding the clinical dilemmas that shape medical students’ ethical development: Questionnaire survey and focus group study. BMJ, 322(7288), 709–710.

    Article  Google Scholar 

  • Inui, T. S. (2003). A flag in the wind: Educating for professionalism in medicine. Washington: Association of American Medical Colleges.

    Google Scholar 

  • Jameton, A. (1984). Nursing practice: The ethical issues. New York, NY: Prentice Hall.

    Google Scholar 

  • Karnieli-Miller, O. P., Vu, T. R. M. D., Holtman, M. C. P., Clyman, S. G. M. D., & Inui, T. S. S. M. D. (2010). Medical students’ professionalism narratives: A window on the informal and hidden curriculum. Academic Medicine, 85(1), 124–133.

    Article  Google Scholar 

  • Kelly, E. M. D. M., & Nisker, J. M. D. P. (2009). Increasing bioethics education in preclinical medical curricula: What ethical dilemmas do clinical clerks experience? [Miscellaneous Article]. Academic Medicine, 84(4), 498–504.

    Article  Google Scholar 

  • Klein, S. M. (2009). Moral distress in pediatric palliative care: A case study. Journal of Pain and Symptom Management, 38(1), 157–160.

    Article  Google Scholar 

  • Knight, L. V., & Rees, C. E. (2007). “Enough is enough, I don’t want any audience”: Exploring medical students’ explanations of consent-related behaviours. Advances in Health Sciences Education, 1(-1), 1–20.

    Google Scholar 

  • Kosmicki, F. X., & Gilickauf-Hughes, C. (1997). Catharsis in psychotherapy. Psychotherapy, 341, 54–159.

    Google Scholar 

  • Labov, W. (1997) Some further steps in narrative analysis. The Journal of Narrative and Life History, 7, 395–415.

    Google Scholar 

  • Labov, W., & Waletzky, J. (1967). Narrative analysis. Oral versions of personal experience. In J. Helm (Ed.), Essays on the verbal and visual arts (pp. 12–44). Seattle: American Ethnological Society/University of Washington Press.

    Google Scholar 

  • Lazarus, R. S. (1991). Emotion and adaptation. New York: Oxford University Press.

    Google Scholar 

  • Maxwell, J. (2010). Using numbers in qualitative research. Qualitative Inquiry, 16, 475–482.

    Article  Google Scholar 

  • Mead, N., & Bower, P. (2000) Patient-centredness: a conceptual framework and review of the empirical literature. Social Science & Medicine, 51, 1087–110.

    Google Scholar 

  • Monrouxe, L. V. (2009). Negotiating professional identities: Dominant and contesting narratives in medical students’ longitudinal audio diaries. Current Narratives, 1, 41–59.

    Google Scholar 

  • Monrouxe, L. V. (2010). Identity, identification and medical education: Why should we care? Medical Education, 44(1), 40–49.

    Article  Google Scholar 

  • Monrouxe, L. V., Rees, C. E., & Bradley, P. (2009). The construction of patients’ involvement in hospital bedside teaching encounters. Qualitative Health Research, 1(7), 918–930.

    Article  Google Scholar 

  • Monrouxe, L. V., Rees, C. E., & Hu, W. (2011). Differences in medical students’ explicit discourses of professionalism: Acting, representing, becoming. Medical Education, 45, 585–602.

    Article  Google Scholar 

  • Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., et al. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine, 86(8), 996–1009.

    Article  Google Scholar 

  • New South Wales Medical Board. (2005). Code of professional conduct: Duties of a doctor registered with the New South Wales Medical Board Retrieved 16.10.08, 2008, from http://www.nswmb.org.au/index.pl?page=59.

  • Parliamentary and Health Service Ombudsman. (2011). Care and compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people.

  • Pauly, B., Varcoe, C., Storch, J., & Newton, L. (2009). Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics, 16(5), 561-573.

    Google Scholar 

  • Pennebaker, J., Booth, R., & Francis, M. (2007a). In N. Z. The University of Texas at Austin and The University of Auckland (Eds.). Operator’s manual, linguistic inquiry and word count: LIWC2007. Austin, Texas: LIWC.net.

  • Pennebaker, J. W., Chung, C. K., Ireland, M., Gonzales, A., & Booth, R. J. (2007b). The development and psychometric properties of LIWC2007 [LIWC manual]. Austin, Texas: LIWC.net.

    Google Scholar 

  • Pennebaker, J. W., & Francis, M. E. (1996). Cognitive, emotional, and language processes in disclosure. Cognition and Emotion, 10, 601–626.

    Google Scholar 

  • Pennebaker, J. W., & Graybeal, A. (2001). Patterns of natural language use: Disclosure, personality, and social integration. Current Directions, 10, 90–93.

    Google Scholar 

  • Pennebaker, J. W., Mehl, M. R., & Niederhoffer, K. G. (2003). Psychological aspects of natural language use: Our words, our selves. Annual Review of Psychology, 54, 547–577.

    Article  Google Scholar 

  • Rees, C. E., & Knight, L. V. (2008). Thinking ‘no’ but saying ‘yes’ to student presence in general practice consultations: politeness theory insights. Medical Education, 42(12), 1152–1154.

    Article  Google Scholar 

  • Rees, C. E., Knight, L. V., & Wilkinson, C. E. (2007). Doctors being up there and we being down here: A metaphorical analysis of talk about student/doctor-patient relationships. Social Science and Medicine, 65(4), 725–737.

    Article  Google Scholar 

  • Rees, C. E., & Monrouxe, L. V. (2008). ‘Is it alright if I-um-we unbutton your pyjama top now?’ Pronominal use in bedside teaching encounters. Communication and Medicine, 5(2), 171–182.

    Google Scholar 

  • Rees, C. E., & Monrouxe, L. V. (2011a). Medical students learning intimate examinations without valid consent: A multicentre study. Medical Education, 45(3), 261–272.

    Article  Google Scholar 

  • Rees, C. E., & Monrouxe, L. V. (2011b). “A morning since eight of pure grill”: A multischool qualitative study of student abuse. Academic Medicine, 86(11), 1374–1382.

    Article  Google Scholar 

  • Rees, C. E., & Monrouxe, L. V. (in press). “Oh my God uh uh uh”: Laughter for coping in medical students’ personal incident narratives of professionalism dilemmas. In C. Figley, P. Huggard, & C. Rees (Eds.), First do no self-harm: Understanding and promoting physician stress resilience. Oxford: Oxford University Press.

  • Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman & R. G. Burgess (Eds.), Analyzing qualitative data. London: Routledge.

    Google Scholar 

  • Roseman, I. J. (1991). Appraisal determinants of discrete emotions. Cognition and Emotion, 5(3), 161–200.

    Article  Google Scholar 

  • Rosenthal, R. (1991). Meta-analytic procedures for social research (2nd ed.). Newbury Park, CA: Sage.

    Google Scholar 

  • Royal College of Nursing. (2009). In R. C. O. Nursing (Ed.). Small changes make a big difference: How you can influence to deliver dignified care. London: Royal College of Nursing.

  • Sandelowski, M., Voils, C. I., & Knafl, G. (2009). On quantitizing. Journal of Mixed Method Research, 3, 208–222.

    Article  Google Scholar 

  • Schiffrin, D. (1994). Approaches to discourse. Cambridge, USA: Blackwell Publishers.

    Google Scholar 

  • Tausczik, Y. R., & Pennebaker, J. W. (2010). The psychological meaning of words: LIWC and computerized text analysis methods. Journal of Language and Social Psychology, 29(1), 24–54.

    Article  Google Scholar 

  • Wiggleton, C. M. D., Petrusa, E. P., Loomis, K. M. D., Tarpley, J. M. D., Tarpley, M., O’Gorman, M. L. M., et al. (2010). Medical students’ experiences of moral distress: Development of a web-based survey. Academic Medicine, 85(1), 111–117.

    Article  Google Scholar 

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Acknowledgments

We thank our study participants for sharing their stories so candidly. We acknowledge Laura Rees-Davies for her assistance in data coding and framework development and Wendy Hu for her assistance in framework development. Thanks to Drs Helen Manson, Andrew Grant and five anonymous reviewers for their useful feedback on an earlier version of the paper. Finally, we would like to acknowledge the contribution of our late colleague Professor Kieran Sweeney to the study: for helping secure funding and for his thoughtful comments on the results before his death. This study was funded by the British Academy [LRG 45505].

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Authors and Affiliations

  1. Institute of Medical Education, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK

    Lynn V. Monrouxe

  2. Centre for Medical Education, College of Medicine, Dentistry and Nursing, University of Dundee, 484 Perth Road, Dundee, DD2 1LR, Scotland, UK

    Charlotte E. Rees

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  1. Lynn V. Monrouxe
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  2. Charlotte E. Rees
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Correspondence to Lynn V. Monrouxe.

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Monrouxe, L.V., Rees, C.E. “It’s just a clash of cultures”: emotional talk within medical students’ narratives of professionalism dilemmas. Adv in Health Sci Educ 17, 671–701 (2012). https://doi.org/10.1007/s10459-011-9342-z

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