Erica Borgstrom

Medical professionalism: conflicting values for tomorrow's doctors.

BackgroundNew values and practices associated with medical professionalism have created an increased interest in the concept. In the United Kingdom, it is a current concern in medical education and in the development of doctor appraisal and revalidation.ObjectiveTo investigate how final year medical students experience and interpret new values of professionalism as they emerge in relation to confronting dying patients and as they potentially conflict with older values that emerge through hidden dimensions of the curriculum.MethodsQualitative study using interpretative discourse analysis of anonymized student reflective portfolios. One hundred twenty-three final year undergraduate medical students (64 male and 59 female) from the University of Cambridge School of Clinical Medicine supplied 116 portfolios from general practice and 118 from hospital settings about patients receiving palliative or end of life care.ResultsProfessional values were prevalent in all the portfolios. Students emphasised patient-centered, holistic care, synonymous with a more contemporary idea of professionalism, in conjunction with values associated with the ‘old’ model of professionalism that had not be directly taught to them. Integrating ‘new’ professional values was at times problematic. Three main areas of potential conflict were identified: ethical considerations, doctor-patient interaction and subjective boundaries. Students explicitly and implicitly discussed several tensions and described strategies to resolve them.ConclusionsThe conflicts outlined arise from the mix of values associated with different models of professionalism. Analysis indicates that ‘new’ models are not simply replacing existing elements. Whilst this analysis is of accounts from students within one UK medical school, the experience of conflict between different notions of professionalism and the three broad domains in which this conflict arises are relevant in other areas of medicine and in different national contexts.

Choice and compassion at the end of life:A critical analysis of recent English policy discourse

End of life care in England has recently been framed by two very different discourses. One (connected to advance care planning) promotes personal choice, the other promotes compassionate care; both are prominent in professional, policy and media settings. The article outlines the history of who promoted each discourse from 2008 to early 2015, when, why and how and this was done. Each discourse is then critically analysed from a standpoint that takes account of bodily decline, structural constraints, and human relationality. We focus on the biggest group of those nearing the end of their life, namely frail very old people suffering multiple conditions. In their care within contemporary healthcare organisations, choice becomes a tick box and compassion a commodity. Informed choice, whether at the end of life or in advance of it, does not guarantee the death the person wants, especially for those dying of conditions other than cancer and in the absence of universally available skilled and compassionate care. Enabling healthcare staff to provide compassionate, relational care, however, implies reversing the philosophical, political and financial direction of healthcare in the UK and most other Anglophone countries.

Learning to care: medical students' reported value and evaluation of palliative care teaching involving meeting patients and reflective writing.

BackgroundOver recent years there has been an increase in teaching of both palliative care and reflective practice in UK medical schools. The palliative care teaching at the University of Cambridge School of Clinical Medicine is multi-faceted and involves students writing reflective essays after individually meeting patients approaching the end of life during their final year general practice and hospital medicine placements. This paper draws on two studies examining this teaching element to analyse what the students found valuable about it and to comment on the practice of meeting patients and subsequent reflective writing.MethodsTwo studies have explored students’ perceptions of these course components. The first was a thematic analysis of 234 reflective essays from 123 students written in 2007-2008, including examining what students wrote about the exercise itself. The second project involved a semi-structured questionnaire that students completed anonymously; this paper reports on the free text elements of that study [sample size =107]. Since similar themes were found in both studies, the coding structures from each project were compared and combined, enabling triangulation of the findings around what the students found valuable from the palliative care teaching involving meeting patients and reflective writing.ResultsOverall, students reported that these components of the palliative care teaching are valuable. Four main themes were identified as aspects that students valued: (1) dedicated time with patients, (2) learning about wider elements of treatment and holistic care, (3) practicing communication skills, and (4) learning about themselves through reflective writing. Some students expressed a dislike for having to formally write a reflective essay.ConclusionIt is possible to arrange for all of the medical students to individually meet at least two patients receiving palliative or end of life care. Students found these encounters valuable and many wrote about the benefit of formally writing about these experiences. Students reported finding this model useful in widening their skill-set and understanding of palliative care.

Planning for an (un)certain future: Choice within English end-of-life care

Neoliberal policies are shaping the healthcare landscape by emphasizing individual choice. End-of-life care is a case in point as patient choice, through advance care planning, is a key conceptual framework for motivating service development and provision. Based on qualitative ethnographic research in England, this article describes what choice is and how it is enacted in the context of end-of-life care. Within policy, choice represents individual autonomy and is a goal to strive towards. In order to enable choice, healthcare professionals are to openly discuss dying with patients and in turn, patients are expected to express their preferences. However, by focusing on two case studies, the article demonstrates how people struggle to articulate choice in these ways and the preferences expressed represent the complex contexts in which care is performed. Although death is certain, the possibility of control alluded to by choice rhetoric is not realized in practice.

Social death in end-of-life care policy

Social death denotes a loss of personhood. The concept of social death is engaged with in English end-of-life care policy that sees social death before physical death as a problem. Policy-makers posit that dying persons are likely to be subject to a social death prior to their physical death unless they play an active and aware role in planning their death, facilitated through communication and access to services. Such a view foregrounds a vision of agency and does not address Sudnows critique of how care of the dying focuses on the body.

Advance care planning: between tools and relational end-of-life care?

The way in which end-of-life care is delivered in the UK has changed dramatically over the last few years. Owing to the changes in systems and care practice promoted in the End of Life Care Strategy1 more people have access to higher quality care, including advance care planning and symptom management. Drawing on the ‘best practice’ at the time, the Strategy recommended the use of several tools to facilitate identifying dying patients, communicating and planning future care, and coordinating otherwise disparate services. These changes have not gone unnoticed: in 2010, the UK was considered as the best place to die by the Economist Intelligence Unit,2 and recent UK data released as part of Dying Matters Awareness week suggest people are more comfortable talking about death and dying now than they were 10 years ago.3 Yet, end-of-life care has been described as ‘failing’, in a 2015 Parliamentary and Health Service Ombudsmans report, particularly in terms of discussing dying and documenting patient preferences.4 A theme appears to be emerging from the history of attempts to scale up hospice-style care into acute and mainstream health services. It may be that focusing on the tools and documents of advance care planning risks undermining the discussions and relational care they are intended to support. This is evident in observations on how advance care planning documents and tools, such as the Preferred Priorities of Care, among others, have …

Applying social theory to understand health-related behaviours

Health-related behaviours are a concern for contemporary health policy and practice given their association with a range of illness outcomes. Many of the policies and interventions aimed at changing health-related behaviours assume that people are more or less free to choose their behaviour and how they experience health. Within sociology and anthropology, these behaviours are viewed not as acts of choice but as actions and practices situated within a larger sociocultural context. In this paper, we outline three theoretical perspectives useful in understanding behaviours that may influence ones health in this wider context: theories of social practice, social networks and interactionism. We argue that by better understanding how health-related behaviours are performed in peoples everyday lives, more suitable interventions and clinical management can be developed.

Introduction: researching death, dying and bereavement

As early career researchers studying the end of life, we recognise that scholarly activity in the field of death studies – an umbrella term for research spanning all aspects of death, dying and ber...

What’s in a name? From pathways to plans in end of life care

It is not surprising that the independent reviewers of the Liverpool care pathway suggested removing the term “pathway” from discussions about end of life care.1 2 Language influences the way people perceive the world and shapes the way we live.3 The term pathway metaphorically appeals to an irreversible journey of decline. Yet, as the Liverpool care pathway recognises, death is not …

Using an Ethnographic Approach to Study End-of-Life Care: Reflections from Research Encounters in England

This chapter is based on reflections about the various kinds of explanatory work that I had to do with various stakeholders to legitimise and negotiate studying end-of-life care in England ethnographically. By examining the responses I received, I comment on how this explanatory work and framing shaped what I could ultimately study, the knowledge that could be produced, and my relationship to the project. Ultimately, this chapter invites ethnographers to be reflexive about the ways we position our methodological stances and ourselves as researchers within health-related fields and how this constructs our subjects of study.