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.
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.
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.
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).
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.”
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.
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
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.
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.
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.
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.
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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