From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees

Abstract

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

The formation of physician altruism

“…Medical ethics and education literature support this view and report a number of causes related to experiences medical students make with their teachers, mentors, and instructors. These causes are, for instance, disillusionment early on in medical education by perceived discrepancy in the quality of care patients receive (e.g., Davis et al, 2001), moral distress (e.g., Bordignon et al, 2020;Hilliard et al, 2007;Liu et al, 2022), ethical conflicts and dilemmas 25 (e.g., Hilliard et al, 2007;Kelly and Nisker, 2009;Liu et al, 2022), emotional dissonance (e.g., Liu et al, 2022), and negative role modeling of teachers by inadequate supervision and poor professional practice (e.g., Davis et al, 2001;Paice et al, 2002); see also Kosse et al (2020) for role models' impact in early childhood. Although the listed factors cannot be checked by our data, it seems plausible that many of them contribute to the observed decay of patient-regarding altruism in the course of medical students' education.…”

“…In contrast, evidence in the economics literature exists on the formation of preferences in early childhood (e.g., Cappelen et al, 2020;Kosse et al, 2020) and on the influence of practical experience on preference formation (Malmendier and Nagel, 2015;Malmendier et al, 2020;Malmendier, 2021). Moreover, the medical education and medical ethics literature reports a decay of patient-regarding attitudes and empathy during medical education (e.g., Davis et al, 2001;Hojat et al, 2009;Stratta et al, 2016;Bordignon et al, 2020;Liu et al, 2022).…”

Systems-Based Practice in Graduate Medical Education: Evolving Toward an Ideal Future State

“…19 As a consequence, learners may risk becoming detached and disconnected from the more complex aspects of SBP for structurally marginalized patient populations. 15 Taken together, these reflections on the current state of SBP curricula and competencies point to important directions for the academic medical community to consider. As a result, we suggest potential ways for the medical education community to shift from SBP 1.0 to SBP 2.0.…”

“…For instance, SBP implementation has not adequately incorporated health equity and structural competency (i.e., the ability to understand structures and systems) 19 . As a consequence, learners may risk becoming detached and disconnected from the more complex aspects of SBP for structurally marginalized patient populations 15 . Taken together, these reflections on the current state of SBP curricula and competencies point to important directions for the academic medical community to consider.…”

“…Over time, and despite efforts to redefine and co-construct SBP competencies, there have also been well-documented stumbling blocks 3,10,14 . Checkbox mentalities, focused on satisfying regulatory requirements, have resulted in SBP courses that are disconnected from the practical reality of medical learners, who often struggle with a lack of SBP role models among faculty members 15 . A recent review suggests that, while some promising advances in SBP knowledge and application have been demonstrated, 2 there were also perceptions that SBP teaching has eroded the amount of curricular time available for more medically focused competencies 16 .…”