Day Leora Branfield, Saunders Stephanie, Steinberg Leah, Ginsburg Shiphra, Soong Christine
Department of Medicine, University of Toronto, Ontario, Canada.
Department of Rehabilitation Sciences, McMaster University, Ontario, Canada.
Can Med Educ J. 2022 Mar 2;13(1):17-28. doi: 10.36834/cmej.71956. eCollection 2022 Mar.
Residents frequently lead goals of care (GoC) conversations with patients and families to explore patient values and preferences and to establish patient-centered care plans. However, previous work has shown that the hidden curriculum may promote physician-driven agendas and poor communication in these discussions. We previously developed an online learning (e-learning) module that teaches a patient-centered approach to GoC conversations. We sought to explore residents' experiences and how the module might counteract the impact of the hidden curriculum on residents' perceptions and approaches to GoC conversations.
Eleven first-year internal medicine residents from the University of Toronto underwent semi-structured interviews before and after completing the module. Themes were identified using principles of constructivist grounded theory.
Prior to module completion, residents described institutional and hierarchical pressures to "get the DNR" (Do-Not-Resuscitate), leading to physician-centered GoC conversations focused on code status, documentation, and efficiency. Tensions between formal and hidden curricula led to emotional dissonance and distress. However, after module completion, residents described new patient-centered conceptualizations and approaches to GoC conversations, feeling empowered to challenge physician-driven agendas. This shift was driven by greater alignment of the new approach with their internalized ethical values, greater tolerance of uncertainty and complexity in GoC decisions, and improved clinical encounters in practice.
An e-learning module focused on teaching an evidence-based, patient-centered approach to GoC conversations appeared to promote a shift in residents' perspectives and approaches that may indirectly mitigate the influence of the hidden curriculum, with the potential to improve quality of communication and care.
住院医师经常主导与患者及其家属的医疗照护目标（GoC）对话，以探究患者的价值观和偏好，并制定以患者为中心的照护计划。然而，先前的研究表明，隐性课程可能会在这些讨论中促成医生主导的议程和沟通不畅。我们之前开发了一个在线学习（电子学习）模块，教授以患者为中心的GoC对话方法。我们试图探究住院医师的体验，以及该模块如何抵消隐性课程对住院医师在GoC对话中的认知和方法的影响。
来自多伦多大学的11名内科一年级住院医师在完成该模块之前和之后接受了半结构化访谈。使用建构主义扎根理论的原则确定主题。
在完成模块之前，住院医师描述了来自机构和层级的压力，要求“获取不要复苏（DNR）医嘱”，导致以医生为中心的GoC对话集中在代码状态、文件记录和效率上。正式课程和隐性课程之间的紧张关系导致了情感失调和困扰。然而，在完成模块之后，住院医师描述了以患者为中心的GoC对话的新观念和方法，感到有能力挑战医生主导的议程。这种转变是由新方法与他们内化的道德价值观的更大一致性、对GoC决策中不确定性和复杂性的更大容忍度以及实践中改善的临床接触驱动的。
一个专注于教授基于证据的、以患者为中心的GoC对话方法的电子学习模块似乎促进了住院医师观点和方法的转变，这可能间接减轻隐性课程的影响，有可能提高沟通和照护质量。
