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Use of vignettes to stimulate reflection on professional dilemmas.


Bernabeo E, Reddy S, Ross K, Chesluk B, Guille R, Holmboe ES. — American Board of Internal Medicine

Ginsburg S. — University of Toronto

Presented: Society of General Internal Medicine Annual Meeting, May 2012

Background: Many believe that the growth and renewal of professional values can serve as a stable foundation for physicians to draw upon amidst challenging and unpredictable times in health care. However, while most physicians embrace professional values, many experience challenges to exhibiting consistent behaviors in practice. Reflecting on their response to professional dilemmas may help practicing physicians identify both internal and external factors contributing to (un)professional behavior.

Methods: A set of vignettes were designed to stimulate physicians' reflection on typically challenging professional situations. The vignettes were grounded in both theory and extant professionalism literature, and emphasize domains such as physician-patient relationships, self-regulation, allocation of resources, conflict of interest and confidentiality. Five focus groups were conducted during which physicians responded to the vignettes, both individually and collectively. Groups (N=40) were comprised of outpatient specialists, outpatient generalists, inpatient specialists, inpatient generalists and one mixed group. Data were analyzed using a constructivist grounded theory approach.

Results: Each scenario was effective in stimulating discussion, resulting in an average of 50 codes per scenario (range 36-93). The scenarios were perceived as authentic and familiar to participants, who endorsed facing similar dilemmas on a regular basis. Debates surrounding areas of professional ambiguity, where there was a perceived lack of understanding of a “right” or “wrong” response to the vignette, were salient, and these cases in particular generated a broad range of responses.

Two main sets of factors appeared to underpin participants' responses to the dilemmas: guiding principles and modifiers. Guiding principles (N=14) included patient welfare and satisfaction, efficiency, confidentiality, availability, transparency, evidence-based medicine, reimbursement and other financial considerations, and legal concerns such as a fear of being sued. Each principle arose in all five FG discussions to some degree. Several (N=6) modifiers were identified, factors which influenced how participants interpreted and acted upon the principles. These included the relationship with the patient or colleague, risk of danger or harm, familiarity with the request, and the type of patient or nature of the illness. Importantly, these two categories are not mutually exclusive, and are often activated together and interact with each other in response to a given scenario. The study findings therefore suggest that physicians respond to professional dilemmas in a highly individualized manner, taking into consideration their resources, environment and setting on a case-by-case basis.

Conclusions: Providing an opportunity for physicians to reflect on professional behavior in an open and safe forum may be a practical way to guide physicians to assess themselves on professional behavior and engage with the complexities of their work. The finding that the focus groups led to reflection at a group level suggests that reflection on professional behavior may require a socially interactive process. The finding that physicians rely on a number of principles and modifiers that interact in complex and often unpredictable ways may help explain the discordance between professional values and behaviors. Emphasizing both the behaviors and the context in which they occur can therefore be seen to be critically important for understanding professionalism in practicing physicians.

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