Do Medical Students Narrative Representations of The Good Doctor Change Over Time? Comparing Humanism Essays From a National Contest in 1999 and 2013

Rutberg, Pooja C. MD; King, Brandy MLIS; Gaufberg, Elizabeth MD, MPH; Brett-MacLean, Pamela PhD; Dinardo, Perry; Frankel, Richard M. PhD

doi: 10.1097/ACM.0000000000001531
Research Reports

Purpose: To explore medical students’ conceptions of “the good doctor” at two points in time separated by 14 years.

Method: The authors conducted qualitative analysis of narrative-based essays. Following a constant comparative method, an emergent relational coding scheme was developed which the authors used to characterize 110 essays submitted to the Arnold P. Gold Foundation Humanism in Medicine Essay Contest in 1999 (n = 50) and 2013 (n = 60) in response to the prompt, “Who is the good doctor?”

Results: The authors identified five relational themes as guiding the day-to-day work and lives of physicians: doctor–patient, doctor–self, doctor–learner, doctor–colleague, and doctor–system/society/profession. The authors noted a highly similar distribution of primary and secondary relational themes for essays from 1999 and 2013. The majority of the essays emphasized the centrality of the doctor–patient relationship. Student essays focused little on teamwork, systems innovation, or technology use—all important developments in contemporary medicine.

Conclusions: Medical students’ narrative reflections are increasingly used as rich sources of information about the lived experience of medical education. The findings reported here suggest that medical students understand the “good doctor” as a relational being, with an enduring emphasis on the doctor–patient relationship. Medical education would benefit from including an emphasis on the relational aspects of medicine. Future research should focus on relational learning as a pedagogical approach that may support the formation of caring, effective physicians embedded in a complex array of relationships within clinical, community, and larger societal contexts.

P.C. Rutberg is clinical instructor, Department of Pediatrics, Harvard Medical School, Boston, and pediatric residency site director, Cambridge Health Alliance, MassGeneral Hospital for Children, Boston, Massachusetts.

B. King is head, Information Services, Arnold P. Gold Foundation Research Institute, Cambridge, Massachusetts.

E. Gaufberg is associate professor of medicine and psychiatry, Harvard Medical School, Boston, Massachusetts; Jean and Harvey Picker Director, Arnold P. Gold Foundation Research Institute, Cambridge, Massachusetts; director, Cambridge Health Alliance Center for Professional Development, Cambridge, Massachusetts; and leader, Patient–Doctor Course, Harvard Medical School Cambridge Integrated Clerkship, Cambridge, Massachusetts.

P. Brett-MacLean is associate professor of psychiatry, director, Arts & Humanities in Health & Medicine program, Faculty of Medicine & Dentistry, and adjunct associate professor, John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada.

P. Dinardo is research intern, Arnold P. Gold Foundation Research Institute, Cambridge, Massachusetts.

R.M. Frankel is professor of medicine and geriatrics, Indiana University School of Medicine, Indianapolis, Indiana; senior scientist, Regenstrief Institute Center for Health Services Research and Richard L. Roudebush VA Center for Healthcare Information and Communication, Indianapolis, Indiana; and staff, Cleveland Clinic Education Institute, Cleveland Ohio.

Editor’s Note: Although the winning Arnold P. Gold Foundations essays were not published in Academic Medicine until 2001, those who are interested in reading the winners from the 2013 essay contest that asked students, “Who is the good doctor?” can access them by searching for “2013 essay contest” on the Academic Medicine Web site.

Funding/Support: None reported.

Other disclosure: None reported.

Ethical approval: The institutional review board of Cambridge Health Alliance waived the need for informed consent for analysis of the essays.

Disclaimer: The winning Arnold P. Gold Foundation essays have been published in Academic Medicine each year since 2001.

Previous presentations: Previous versions of this have been presented at Creating Space IV: Exploring Paradigms of Scholarship and Practice, Presymposium, Canadian Conference on Medical Education, April 2014, Ottawa, Ontario, Canada, and at the Gold Humanism Honor Society Biennial National Conference on Humanism: Advancing Humanism in the Age of Technology, October 2014, Atlanta, Georgia.

Correspondence should be addressed to Pooja C. Rutberg, Cambridge Health Alliance–Pediatrics Department, 1493 Cambridge St., Cambridge, MA 02139-1047; telephone: (617) 665-1497; e-mail: prutberg@challiance.org; Twitter: @GoldFdtn.

Article Outline

I will tell you something about stories … They aren’t just entertainment. Don’t be fooled. They are all we have, you see, all we have to fight off illness and death.

―Leslie Marmon Silko, Ceremony1

Conceptions of the “good doctor” have helped shape the story of medicine since the time of Hippocrates.2 In the past several decades, numerous studies and reports have explored the question of who and what the “good doctor” is in the context of contemporary medical practice.3–7 While these reports have been valuable in outlining community norms and guiding educational programming, few studies have explored how different societal contexts across time may influence medical students’ conceptions of the “good doctor.”2–5

Additionally, numerous authors have described the use of written reflective narratives in medical education, particularly in relation to supporting students’ professional identity formation.8–11 Written narratives also offer important means for medical educators to understand students’ developmental trajectory as physicians in training.

The annual Arnold P. Gold Foundation (APGF) essay contest invites medical students to engage in a reflective writing exercise around a theme or quote related to humanism in medicine. Since its inception in 1999, medical students from the United States and Canada have responded with rich narratives that provide insight into how students who are learning how to be doctors are supported or hindered in their understanding and expression of humanism. In both 1999 and 2013 the Gold Foundation used the prompt “Who is the good doctor?” for its essay contest.

The use of the same prompt with a 14-year gap has provided a unique opportunity to study medical students’ conceptions of whom they consider the “good doctor” to be at two distinct points in time. Given the profound changes that have influenced medicine over the past decade and a half, including a growing emphasis on patient-centered care, social accountability, interprofessional team-based care, and the use of computer-based technologies, we compared conceptions of the “good doctor” as described in 1999 with those described in 2013, and we explored whether the descriptions in 2013 more closely reflect the realities of contemporary medical practice.

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Method

To explore changes in medical students’ views of “good doctors” at two points in time separated by 14 years, we reviewed all essays submitted to the APGF essay contest in 1999 and 2013. At both points in time, the prompt for the essay was, “Who is the good doctor?” Students submitted 198 essays in 1999 and 191 in 2013. The institutional review board of Cambridge Health Alliance granted an exemption to the study and waived the need for informed consent for analysis and publication of deidentified quotes from the essays. When students submitted their essays to the APGF, they signed a waiver allowing publication of parts or all of their essays. All essays were anonymized prior to analysis.

In our initial review of the data, we observed that some essays described highly respected role models whom the writers considered to be “good doctors.” Other submissions were abstract philosophical essays comprising lists of traits and qualities that characterize the ideal “good doctor”; these did not include a portrayal of any specific, actual individual physician. As compared with lists (“A good doctor is thoughtful, empathic, and puts the patient’s needs before his or her own”), narratives (“I was impressed as Dr. Jones reached for Mrs. Smith’s hand and sat with her in silence as she absorbed the news”) have been described as “the basic medium in which human beings speak, think, grow into selves, and understand others.”12 We chose to focus on the narrative essays since, compared with abstract descriptions or lists of facts and attributes, they offered a more robust and nuanced opportunity to explore and compare students’ perspectives.13

We conducted a qualitative analysis of the essays using the constant comparative method recommended by Glaser and Strauss.14 All of us (save one [P.D.]) began the process by individually reading the same randomly selected sample of 25 essays from 1999 and 25 essays from 2013. We collectively identified provisional “thematic elements” such as compassion and empathy, treating the whole person, privilege to serve, and reflective practice. At the next level of abstraction, we developed a coding scheme into which we organized the thematic elements into an emergent relational coding framework, similar to those used by Rita Charon15 and by Carol P. Tresolini and the Pew Fetzer Task Force.16 We continued this process, reading additional essays, until we achieved thematic saturation (i.e., no new themes emerged).

Once we had established a coding framework that included both relational themes and associated thematic elements, we used an iterative consensus-building approach to analyze all the essays in the sample. Each essay was independently coded by two or more authors who assigned:

1. A single primary relational theme, defined as the central message of the narrative.

2. Where present, up to two secondary relational themes, defined as adding significant supplementary detail to describe the “good doctor.”

3. Supporting thematic elements for each relational theme.

Each of us highlighted specific sentences or text fragments in support of the themes and thematic elements we assigned to each essay. We discussed this coding during in-person and phone meetings, and we reconciled any discrepancies through group-based discussion and consensus. As a final step, we entered the coded data into NVivo 10 qualitative data analysis software (QSR International Pty Ltd., Version 10, 2012). We also used simple descriptive statistics to summarize and compare the frequency of primary and secondary relational themes and associated thematic elements between 1999 and 2013.

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Results

We analyzed a total of 110 essays containing narrative representations or portrayals of actual physicians: 50 from 1999 (25.2% of the 198 submitted that year) and 60 from 2013 (31.4% of the 191 submitted). Table 1 summarizes the demographic characteristics of the students whose essays we analyzed. At both time periods, the essays were evenly distributed between preclerkship and clerkship students. In both 1999 and 2013, the described “good doctors” were primarily characterized as male physicians practicing in a first-world hospital or clinical setting (Table 2).

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Thematic analysis

We identified five relational themes as guiding the day-to-day work and lives of physicians described in the essays:

1. Doctor–patient

2. Doctor–self

3. Doctor–learner

4. Doctor–colleague

5. Doctor–system/society/profession

We observed a highly similar distribution of primary and secondary relational themes for the essays in both 1999 and 2013 (see Table 3). We detected no difference in the number of themes assigned to the essays at the two time periods. We assigned a single primary relational theme to about a third of the essays (n = 29); we assigned both a primary and a secondary theme to about 40% of the essays (n = 47); and we assigned one primary and two secondary themes to about a third of the essays (n = 34). On average, we assigned the essays from both 1999 and 2013 two themes.

We have provided illustrative quotes associated with the five relational themes in Table 4, and a summary of thematic elements associated with each relational theme in Table 5.

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Relational theme 1: The doctor–patient relationship

The doctor–patient relationship was the primary theme in 38 (76.0%) of the 1999 and 47 (78.3%) of the 2013 essays. Together with secondary themes, almost all essays (48 [92.0%] of the 1999 essays and 56 [92.3%] of the 2013 essays) contained thematic content related to the doctor–patient relationship. As illustrated by the sample quotes in Table 4, students provided nuanced portrayals of the various ways “good doctors” interacted with patients. Students described physicians whose “entire heart and soul were immersed in the desire to help people,” and who were “not only concerned with murmurs of the valves but other murmurs that arise from sorrow, sadness, and depression.” These essays highlighted clinical excellence, as well as key aspects of patient-centered care, such as compassion and empathy, treating the whole person, and partnering with patients and families. The distribution of various thematic elements associated with the doctor–patient relationship theme, summarized in Table 5, highlight its complexity.

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Relational theme 2: The doctor–self relationship

The doctor–self relationship was the primary theme in 3 (6.0%) essays in 1999 and 5 (8.3%) in 2013; it was the secondary theme in 24 (68.6%) essays in 1999 and 25 (58.1%) in 2013. As illustrated by the quotes in Table 4, students recognized the complex personal qualities of physicians who strived to be caring, compassionate, and skilled practitioners. Essays that included doctor–self thematic content described a wide range of emotions and characteristics relating to the personhood of the “good doctor” (Table 5). Of note, humility was the most common thematic element in this theme. The student essayists also frequently described the “good doctor” as being accepting of others, “willing to learn, to be affected, and to be humbled by” patients.

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Relational theme 3: The doctor–learner relationship

The doctor–learner relationship was a primary theme in 5 (10.0%) of the 1999 and 4 (6.7%) of the 2013 essays, and a secondary theme in 5 (14.3%) of the 1999 and 14 (32.6%) of the 2013 essays. Interestingly, 2013 student essayists more frequently described exemplary physicians as inspiring role models—“equal part healer and advocate”—compared with their 1999 counterparts: 12 (66.7%) in 2013, compared with 3 (30.0%) in 1999.

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Relational theme 4: The doctor–colleague relationship

Including both primary and secondary themes, only 8 (16.0%) of the 1999 essays and 4 (6.7%) of the 2013 essays included thematic content related to the doctor–colleague relationship. This relational theme was not well articulated; essay descriptions were limited to collegial communication, teamwork, and leadership (see Table 5).

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Relational theme 5: The doctor–system/society/profession relationship

Even as attention to social accountability in medicine is increasing, we identified relational activity associated with systems-based and societal concerns as a primary theme in only 3 (6.0%) of essays in 1999 and 3 (5.0%) in 2013, and as a secondary theme in only 4 (11.4%) of the essays in 1999 and 10 (23.3%) in 2013. Awareness of social determinants of health, health inequities, and commitment to social justice was a prominent feature of the essays which included this thematic content (Table 5). Students described doctors who help “human beings break the cycle of addiction and homelessness, which binds them to their current state” and physicians whose work “transcends the hospital.”

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Discussion

The annual APGF essay contest offers a unique opportunity to learn about medical students’ understandings of and insights into humanism in medicine. The essays we analyzed offer a rich source of comparative information about permanence and change in medical students’ perspectives of the “good doctor” at two points in time (1999 and 2013), and the extent to which changing social norms are reflected in students’ representations.

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Relational framework

Our analysis of the 1999 and 2013 narrative-based essays (n = 110) resulted in a coding framework that included five cardinal relationships: doctor–patient, doctor–self, doctor–learner, doctor–colleague, and doctor–system/society/profession. While others have described the role of the doctor in relational terms,15,16 this is the first study we are aware of in which an emergent relational framework has been used to explore and compare medical students’ conceptualization of the “good doctor” at two points in time. Notably, an earlier study at five different medical schools found that faculty valued the positive relational aspects of their institutions, even as they recognized that such settings tended to value individual productivity, self-promotion, and hierarchical structures.17 Specifically, similar to the students in our analysis, faculty members asserted that they valued positive relationships with patients and learners and collaboration with colleagues.17

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Role and influence of relationships on professional identity formation: Implications for medical education

Our findings suggest that students understand the complexities of good doctoring and its implications for their own professional development in terms of relationships, rather than individual heroic acts or isolated behaviors. There is literature to support this perspective: Monrouxe18 has drawn attention to interactional aspects of identity, asserting that “identities are developed in relational settings through activities” and that “relationships are the central components of identification.” This view contrasts with skills-based competency frameworks (such as the Accreditation Council for Graduate Medical Education’s milestones) that cast professional development as an individual achievement, rather than an ongoing, relationally engaged endeavor.

Striving to learn more from students about their perceptions of the “good doctor” and how those perceptions relate to identity formation may be useful both in developing curricula that address the educational needs of an increasingly diverse medical student body, and for preparing medical students to work effectively in complex health care systems to meet the changing needs of society. Meeting students where they are in their professional development is a primary precept of adult learning theory.19 Understanding and acknowledging differences in time, space, and experience among various cohorts of students and faculty may help educators as they develop curricula and create educational environments that support students in developing their professional identities in an ever-evolving practice landscape. The essays we analyzed provide evidence that medical students appreciate that excellence in clinical practice is critically dependent on the ability to learn and work relationally.20,21 Given this emphasis, we wonder how current educational strategies can support the professional identity formation of students in ways that strengthen the development of the “relational being” in medicine.22 Relational learning as a pedagogical approach may support the formation of caring, effective physicians. Our findings also highlight the need to ensure that relationships with role models, patients, and other members of the health care team are highlighted dimensions of the formal and informal curriculum.16

Notably, the majority of the “good doctors” described in the essays were male doctors practicing in first-world settings. It is important for students to have diverse role models who allow them to imagine themselves as successful physicians in the future.23 Greater than 50% of current medical students are female, and we wonder how and when cultural stereotypes within medical education and the broader culture will begin to reflect this reality.

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Evolution over 14 years

Much as others have explored new physicians’ preparedness for practice,24–26 we wondered if conceptions of the “good doctor” held by a recent, compared with an earlier, cohort of medical students reflected the realities of contemporary medical practice. At two points, separated by a span of 14 years, the single theme that remained foundational to being a good doctor, according to the medical student essayists in our study, is the doctor–patient relationship. Despite the changes that have occurred in medicine, health care, and society over the last decade and a half, we found a highly similar distribution of primary and secondary themes between the two time periods in which essays were collected. The lack of emphasis on the doctor–colleague relationship, especially in the 2013 essays, is noteworthy given the increasing importance of teamwork in clinical practice. In addition, the broader role of a physician as a system innovator and/or effective technology user was not significantly featured in the essays we analyzed, despite the increasing emphasis placed on these roles.

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Limitations

We are aware of a number of limitations in our study. The essay authors are self-selected individuals who were aware that the APGF is an organization dedicated to promoting humanism in medicine. Most, if not all, of the students entered the competition hoping that their submission would win. Some may have written “to the test,” providing thematic content they believed would conform to what the judges would view as valuable.27 As such, those who submitted essays are likely not representative of all medical students in the United States and Canada. In addition, we chose to analyze a small proportion (about 30%) of the total essays, specifically those that included descriptive portrayals of actual exemplary physician role models. Although some may believe that restricting our inquiry to only narrative configurations of the “good doctor” might constitute a limitation, we believe this choice afforded us an important opportunity to explore and begin a dialogue about the relational aspects of identify formation in medical education.

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Future research

What does the “good doctor” in the 21st century look like? As we seek answers to this question for the present and the future, medical students are a source of idealism and optimism. Given our findings, future research might include investigation of the relational aspects of identity formation, as well as investigation of the ways in which students learn about, adjust to, and make sense of the contemporary realities of medicine, while attempting to hold onto their hopes and idealism for the future. Analysis of APGF student essays containing lists of characteristics of the “good doctor,” as well as student essays describing the “good doctor” obtained from diverse groups (e.g., underrepresented minority students, students in other health professions, residents and fellows, clinical preceptors, the public), would also be useful in establishing the generalizability of our relational framework within and across disciplines, levels of learning, and society.

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Conclusions

Rita Charon15 has argued that “the effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others.” Medical students’ stories and narratives provide important means of conveying and understanding how they learn their craft and become the doctors they hope to become. Stories are also the primary medium through which faculty preceptors and role models relate their experiences to students and one another. Through this research, in response to reading and reflecting on the student essays we were analyzing, we frequently found ourselves telling stories of our own professional development. As we reflexively developed our consensus-based interpretive framework we were also, in essence, communicating across generations with medical students at two points in time as we compared our hopes, dreams, perspectives, and understandings with theirs. Although not our formal purpose, one unanticipated outcome of our narrative inquiry was that we drew closer to the writers, and perhaps their generations, as we read and re-read their essays. Immersed within the relationships highlighted in their narrative essays, we were heartened by the enduring prominence of the doctor–patient relationship even as we noted disconnects with contemporary medical practice. As Bleakley28 has noted, “There are no doctors without patients.” We are hopeful that in becoming more attuned to the exquisite observations the student essayists made about good doctors, as well as those that were missing, all of us may be more fully prepared to develop identity constructions informed by societal and health care system challenges and opportunities while remaining grounded in an ecosystem of relationships (with patients, learners, colleagues, and self). Our hope is that relational intelligence becomes woven into the fabric of medical education and that medical education recognizes medicine’s social contract and humanism as key to good doctoring today and in the future.29

Acknowledgments: The authors wish to thank the Arnold P. Gold Foundation.

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