Anyta Pinasthika^1,2
Rita Mustika^1,2
1 Department of Medical Education Faculty of Medicine Universitas Indonesia
2 Medical Education Collaboration Cluster, Indonesia Medical Education and Research Institute (IMERI)

Background: 
Clinical learning environment plays an important role in residency education, it needs to be supportive in order to improve patient safety and care, and also improve learning for residents. One of the influential aspects of the learning environment is the culture of the workplace, yet it is often undiscussed and taken for granted as part of a hidden curriculum. Culture of medicine is hierarchical. While it is beneficial for residents’ learning through mentorship and role-modeling, also for patient care through decision-making process; it might be stressful for residents as they might not speak out against medical errors or morally conflicting requests done by their seniors, which might allow mistreatment in residents. Thus, this study aims to explore the influence of hierarchical culture of medicine towards the learning process in residency education. 

Summary of Work/Methods:
This is a qualitative study using phenomenology design involving residents in various programs in the Faculty of Medicine Universitas Indonesia. Participants will be selected through a purposive sampling method considering maximum variation as follows: educational level, program and gender. Data will be collected through focus group discussions until data saturation is reached. Data will be analyzed using thematic analysis approach. 

Results:
Data collection and analysis are expected to be finished by the end of December 2023. This study is expected to elaborate on residents’ perceptions regarding culture and norms in learning and working in the clinical learning environment. This study will explore the impact of high power distance in learning and working for residents, drawing the line where this culture becomes negative and allows mistreatment, also identifying the influencing factors. 

Conclusions/Take Home Message:
It is expected that the findings of this study could contribute to efforts in creating a supportive clinical learning environment for residency education, to promote better learning and patient care. 

References (maximum three) 

Jacqueline Cochrane^1,2
Nancy Dudek^2,1, Kelsey Crawford^3,1,2, Lindsay Cowley⁴ and Kori LaDonna^5,6
1 Faculty of Medicine, University of Ottawa
2 The Ottawa Hospital
3 Elisabeth Bruyere Hospital
4 The Ottawa Hospital Research Institute
5 Department of Innovation in Medical Education
6 Faculty of Medicine

Background:
Recent social justice movements and global health emergencies emphasize why patients and broader society need physician advocates. Troublingly, despite the health advocate (HA) role being an assessable competency1, many physicians and trainees feel ill- equipped to advocate effectively. Recognizing this, efforts abound to improve HA training2. Since recent graduates are well-positioned to identify how training influences preparation for practice, our purpose was to explore the perspectives of new-in-practice physicians who identify as motivated advocates. 

Summary of Work:
During semi-structured interviews, we asked 10 physicians within their first five years of practice about their perceived competence and motivation to engage in patient and system-level advocacy. Constructivist grounded theory informed the iterative data collection and analysis process. 

Results:
Participants wished they knew during training how much they would use advocacy in their practice. Participants gleaned adequate patient-level advocacy skills from informal role modelling during training but, despite a keen interest, acquired few system-level advocacy skills. They grappled with lack of preparation and reported waning motivation because of perceived futility, lack of value for advocacy and a need for self-preservation. For these reasons, participants questioned whether system-level advocacy should be expected of all physicians. 

Discussion: 
Although current training frameworks may adequately prepare trainees to advocate for individual patients, system-level advocacy training remains lacking. While patient-level advocacy is part of good care, whether all physicians need to engage in systems-level advocacy deserves closer consideration. 

Conclusions:
Perhaps health advocacy might be re-imagined as a specialized professional calling akin to scholarship and leadership, whereby practicing physicians interested in large- scale engagement can seek additional training. Regardless, for the HA role to be viewed as intrinsic to the physician role, physician advocates need to be valued for contributions across levels. 

Implications for further research:
Expectations that all physicians need to engage in system- level advocacy deserve careful consideration. 

References (maximum three) 

1. CanMEDS Role Health Advocate. Accessed May 17, 2023. https://www.royalcollege.ca/ca/en/canmeds/canmeds-framework/canmeds-role-health- advocate.html 

2. McDonald M, Lavelle C, Wen M, Sherbino J, Hulme J. The state of health advocacy training in postgraduate medical education: a scoping review. Med Educ. 2019;53(12):1209- 1220. doi:10.1111/medu.13929 

Jinelle Ramlackhansingh¹
Fern Brunger¹
1 Memorial University

Standardised Patients (SPs) are part of the OSCE triad of students, examiners and patients. SPs tend to perform as “professional” patients. Previous research show that SPs are “dehumanized”. My research examines this process. 

This critical ethnography examines professional identity development in pre-clinical medical students. Monthly focus groups were conducted with students, supplemented by interviews with faculty and administrative staff. Participant observation of classes and governance meetings contextualized the data. The theoretical frameworks of Bourdieu and Foucault were used in data analysis. 

My research shows how SPs are dehumanized. Administrative staff confirmed that “[SPs are] here just as a warm body” for OSCEs. Students described the SP as a “body to do a physical”. 

The “body” is a “sophisticated prop” used in OSCE. This dehumanization of the SP as a body has been described as reducing patients to be of a “less[er] human herd”. Dehumanization involves the lack of recognition of the person’s experiences and agency. The language used about SPs has the effect of depersonalizing the patient. In this case, the mechanization of the patient to a “body” for examination results in objectification of the patient incapable of emotional responses. 

From a Bourdieusian perspective, the normative assumptions about dehumanized patients that shape and are perpetuated by, the depersonalization of the SP body, impacts the formation of medical professional identity. The conception of the patient as dehumanized is conveyed through the hidden curriculum via the OSCE. Language influences physician and trainee attitudes and biases. Care should be taken to avoid expressions like examining a “body” in clinical examination. 

Faculty and administrative staff involved in clinical skills should be conscious of the language used. 

The de-personification of the patient can be resisted simply by stating that a “person” is here for a complete body examination. 

References (maximum three) 

Dawson, J. (2021). Medically optimised: Healthcare language and dehumanisation. The British Journal of General Practice : The Journal of the Royal College of General Practitioners., 71(706), 224–224. https://doi.org/10.3399/bjgp21X715829 

Gormley, G. J., Johnston, J. L., Cullen, K. M., & Corrigan, M. (2020). Scenes, symbols and social roles: Raising the curtain on OSCE performances. Perspect Med Educ., 2212-277X (Electronic). https://doi.org/10.1007/s40037-020-00593-1 

Nestel, D., & Kneebone, R. (2010). Perspective: Authentic patient perspectives in simulations for procedural and surgical skills. Academic Medicine, 85(5), 889–893. https://doi.org/10.1097/ACM.0b013e3181d749ac