Three ethical conflicts in particular are paradigmatic of what we define as “clerkship ethics.” First, a distinction that differentiates the clerkship student from the practicing physician involves the student’s principal role as a learner. The clerkship student must skillfully balance her commitment to her own education against her commitment to patient care in a fashion that may compromise patient care. While the practicing physician can often resolve the tension between these two goods when they come into conflict, (...) the clerkship student is left with a more ambiguous set of choices. Second, evaluative scrutiny during clinical clerkships often forces medical students to balance doing what is morally fitting against the perceived expectations of the medical teams in which they work. Third and finally, a deeply entrenched culture of medical hierarchy presents a particular challenge to innovation and improvement in ethics education during the clerkship years. Students regard faculty as exemplars, but are not provided with the tools to assess when technical medical competence is not matched by moral competence; moreover, these faculty are unlikely to have experienced the ethics education in which students are asked to demonstrate mastery. (shrink)

PurposeTo explore the mindfulness practice, its long-term effects, facilitators and barriers, in clinical clerkship students 2 years after participation in an 8-week mindfulness-based stress reduction training.MethodA qualitative study was performed by semi-structured in-depth interviews with 16 clinical clerkship students selected by purposive sampling. Students had participated in a MBSR training 2 years before and were asked about their current mindfulness practice, and the long-term effects of the MBSR training. Thematic analysis was conducted using the constant comparison method. Data (...) saturation was reached after 16 interviews.ResultsMost interviewees were still engaged in regular, predominantly informal, mindfulness practice, although some discontinued mindfulness practice and reported an “unchanged lifestyle.” Three main themes came forward; “focused attention and open awareness” during daily activities as core elements of long-term mindfulness practice; “changes in behavior and coping” that resulted from taking a pause, reflecting, recognizing automatic behavioral patterns and making space for a conscious response; “integration in personal and professional life” by enhanced enjoyment of daily activities, improved work-life-balance and making different career choices. Barriers and facilitators in starting and maintaining mindfulness practice were understanding and intention as “pre-conditions”; practical, personal, and professional factors of students in maintaining practice.ConclusionTwo years after participation in a MBSR training, many interviewees were still engaged in mindfulness practice contributing to both personal and professional changes. In light of the high clerkship demands, MBSR training could be a valuable addition to medical curricula, supporting medical students in developing necessary competencies to become well-balanced professionals. (shrink)

Backround Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. Method We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. Results A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (...) (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). Conclusions Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying “ethical” issues, “professional” issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives. (shrink)

This article reports on moral problems that were raised by medical students as the basis for an ethical case-conference in an obstetrics and gynaecology clerkship. After introducing the issue of teaching clinical ethics, the method of our case-conference is explained. Next, the variety of topics and related moral problems are presented. The article continues with a discussion of three distinct and challenging aspects that characterise obstetrics and gynaecology as a domain for teaching clinical ethics. The conclusion puts forward three (...) significant points our review raises. (shrink)

Medical students' professional identity formation is an adaptive, developmental process. PIF is shaped by values implicit in educational practices and in the culture of the learning environment. In 2003, educational leaders at Harvard Medical School created the Cambridge Integrated Clerkship as a new model of clinical education to support PIF intentionally. The CIC, a longitudinal integrated clerkship, differs in structure, processes, and venues from traditional block rotations, while...

The clinical clerkships in medical school are the first formal opportunity for trainees to apply bioethics concepts to clinical encounters. These clerkships are also typically trainees’ first sustained exposure to the “reality” of working in clinical teams and the full force of the challenges and ethical tensions of clinical care. We have developed a specialized, embedded ethics curriculum for Vanderbilt University medical students during their second year to address the unique experience of trainees’ first exposure to clinical care. Our embedded (...) curriculum is centered around core “ethics competencies” specific to the clerkship: for Medicine, advanced planning and end-of-life discussions; for Surgery, informed consent; for Pediatrics, the patient-family-provider triad; for Obstetrics and Gynecology, women’s autonomy, unborn child’s interests, and partner’s rights; and for Neurology/Psychiatry, decision-making capacity. In this paper, we present the rationale for these competencies, how we integrated them into the clerkships, and how we assessed these competencies. We also review the additional ethical issues that have been identified by rotating students in each clerkship and discuss our strategies for continued evolution of our ethics curriculum. (shrink)

One factor that impedes medical students from speaking up about ethical situations is the lack of sufficient knowledge and skills in conflict resolution. This may also affect students’ decision and timing to intervene. This article will provide practical ways to effectively and efficiently address the medical student’s ethical case presented in August A. Culbert et al.’s “Navigating Informed Consent and Patient Safety in Surgery: Lessons for Medical Students and Junior Trainees.”.

Background: It has been widely reported that medical trainees experience situations with profound ethical implications during their clinical rotations. To address this, most U.S. medical schools include ethics curricula in their undergraduate programs. However, the contents of these curricula vary substantially. Our pilot study aimed to discover, from the students’ perspective, how ethics pedagogy prepares medical students for clerkship and what gaps might remain. Methods: This qualitative study organized focus groups of third- and fourth-year medical students. Participants recounted ethical (...) concerns encountered during clerkship rotations and reflected on how their medical school ethics curriculum informed their responses to these scenarios. Transcripts of the focus-group sessions were analyzed using a grounded theory approach to identify common themes that characterized the students’ experiences. Results: While students’ accounts demonstrated a solid grasp of ethical theory and attunement to ethical concerns presented in the clinic, they also consistently evinced an inability to act on these issues given clerks’ particular position in a complex learning hierarchy. Students felt they received too little training in the role-specific application of medical ethics as clinical trainees. We found a desire among trainees for enhanced practical ethics training in preparation for the clerkship phase of medical education. Conclusion: We recommend several strategies that can begin to address these findings. The use of roleplaying with standardized patients can enable students to practice engagement with ethical issues. Conventional ethics courses can focus more on action-based pedagogy and instruction in conflict management techniques. Finally, clear structures for reporting and seeking advice and support for addressing ethical issues can lessen students’ apprehension about acting on ethical concerns. (shrink)

Background: In the university context, assessing students’ attitude, knowledge and opinions when applying an innovative methodological approach to teach professional ethics becomes fundamental to know if the used approach is enough motivating for students. Research objective: To assess the effect of a blended-learning model, based on professional ethics and related to clinical practices, on physiotherapy students’ attitude, knowledge and opinions towards learning professional ethics. Research design and participants: A simple-blind clinical trial was performed (NLM identifier NCT03241693) (control group, n = (...) 64; experimental group, n = 65). Both groups followed clinical practices for 8 months. Control group performed a public exposition of a clinical case about professional ethics. By contrast, an 8-month blended-learning programme regarding professional ethics was worked out for experimental group. An online syllabus and online activities were elaborated, while face-to-face active participation techniques were performed to discuss ethical issues. Students’ attitudes, knowledge and opinions towards learning professional ethics were assessed. Ethical considerations: The study was approved by the University Ethic Committee of Human Research and followed the ethical principles according to the Declaration of Helsinki. Findings: After the programme, attitudes and knowledge towards learning professional ethics of experimental group students significantly improved, while no differences were observed in control group. Moreover, opinions reported an adequate extension of themes and temporization, importance of clinical practices and interest of topics. Case study method and role playing were considered as the most helpful techniques. Conclusion: The blended-learning programme proposed, based on professional ethics and related to clinical practices, improves physiotherapy students’ attitudes, knowledge and opinions towards learning professional ethics. (shrink)

This paper offers a novel, qualitative approach to evaluating the outcomes of integrating humanities and ethics into a newly revised pre-clerkship medical education curriculum. The authors set out to evaluate medical students’ perceptions, learning outcomes, and growth in identity development. Led by a team of interdisciplinary scholars, this qualitative project examines multiple sources of student experience and perception data, including student essays, end-of-year surveys, and semi-structured interviews with students. Data were analyzed using deductive and inductive processes to identify key (...) categories and recurring themes. Results suggest that students not only engaged with the curricular content and met the stated learning objectives but also acknowledged their experience in the humanities and ethics curriculum as an opportunity to reflect, expand their perceptions of medicine (and what it means to be “in” medicine), connect with their classmates, and further cultivate their personal and professional identities. Results of this qualitative study show how and in what ways the ethics and humanities curriculum motivates students past surface-level memorization of factual knowledge and encourages thoughtful analysis and evaluation about how the course material relates to and influences their thinking and how they see themselves as future doctors. The comprehensive qualitative approach reflects a holistic model for evaluating the integration of humanities and ethics into the pre-clerkship medical education curriculum. Future research should examine if this approach provides a protective factor against the demonstrated ethical erosion and empathy decrease during clinical training. (shrink)

Since the founding of the University of Limburg (1974), in The Netherlands, an innovative medical curriculum has been guided by educational principles of problem-orientation, continuous assessment, student initiative and attitude development. The teaching of medical ethics was built into the preclinical curriculum from the start. However, the clinical years remained largely unaffected, and only recently has an effort been made to extend the educational philosophy to this more or less traditional part of medical education. Within this context, an experiment of (...) clinical ethics teaching was introduced in the Obstetrics and Gynaecology (Ob/Gyn) clerkships. The objectives, methods and results of this experimental programme are described in this paper. The success of the teaching is based on three features of the programme: 1) its student-centred approach; 2) the programme is designed in a way similar to regular patient conferences; 3) the programme is taught by a team consisting of both clinician and ethicist. Before starting a longitudinal programme of ethics teaching during the clinical years, it proved very helpful to experiment with a well designed and evaluated pilot programme. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:BreakClarice DouilleBreakWe have low expectations for M3s this early in their clerkships. I'm disappointed in you; I had higher expectations for you.""Be yourself. But …""I can see where ____ was coming from. You lack emotional intelligence.""I expected you to have constant questions because of what's going on with your mom.""Don't insert yourself into conversations.""You are a med student; you don't have a reputation yet … you can't change medicine. (...) Nobody will listen to you.""Everyone is going through something. If you knew half the stuff I'm dealing with, you'd cry. So I know what you're going through with your mom right now is tough, but you need to compartmentalize and be fully present with patients.""We know each other …"I can't get this "feedback" out of my head.________I can't quite escape my mom's breast cancer diagnosis since it is shoved in my face every day. This is exposure therapy like no other. Immediately after seeing my mom for the first time since her diagnosis—seeing her distressed and supporting her after losing 75% of her hair during the four days I was home for a visit—I was thrust into assisting with three mastectomies on my first day of the breast cancer surgery service.My third year of medical school has been more than a struggle. I've accepted going through the motions as the best I can do, for I barely have enough energy to make it through each day. Every time I start feeling relief—like I can come up for air—I'm pushed back down and feel myself drowning. I'm constantly waiting for the next shoe to drop. While I can forget about my grief momentarily, as soon as I slow down, the pain returns in unrelenting multiples, pushing me into a dark hole of self-isolation.All I've been doing is grieving. Grieving my mom's diagnosis and fearing the unknown. Grieving the idea that I'm a subpar daughter. Grieving that I'm a subpar friend. Grieving the idea of medicine I had believed in. I grieve for the medical student I was in the past, who wanted to excel in this setting. I grieve that I cannot be this student because I am frozen in fear. I'm grieving the life I thought I'd have, and the life my mom thought she'd have. I'm grieving the life we lost. Time is standing still and simultaneously going by in a blur. I want to be able to control something in my life. My heart and head are heavy with thoughts of disappointment, overwhelm, anger, guilt, and confusion. This is grief.I need a break, but I fear a break might make things worse. In medical school, we are given no time to be human, to live a life full of joy, pain, achievement, and disappointment. I feel myself cracking. I'm being pulled in a thousand different directions. I might break. I tell myself I should be able to get past this. Everyone has something going on. Why can't I be like everyone else—able to tough it out and do medicine? [End Page E1]During clerkships, we are constantly thrown into vulnerable situations where we show up every day and put our best foot forward to impress our team and attendings. We can't miss a beat. It feels like we must be Superman. Every day, we feel inadequate and have to "fake it till we make it." It's soul-crushing. It's exhausting. Every day is terrifying. We worry about getting "pimped"—if we'll be able to answer any question correctly—if we'll present the patient adequately—hopefully not too long, or not too short—so our attending doesn't become annoyed. We don't know when we're allowed to go home, and it feels like we can't even go to the bathroom or eat without asking permission. It feels like we're back in Kindergarten, except with so much more at stake.I think attendings forget that we're more than... (shrink)

Abstract“Shut the door,” the chief resident said to me. While I was green enough at the beginning of my clinical clerkships to believe that most of my medical education would happen at the bedside, at that moment, I was learning another important fact: a large part of my ethical education was going to happen behind the closed doors of a call room. The health care team was polluted by a pervasive atmosphere of frustration, as silent but tangible as a thick (...) layer of fog, that obscured the patient's ability to evaluate the consequences of the choice that lay before her. The attending did not permit, let alone create, an environment that provided room for dissent.Institutions should encourage the leaders of clinical education to foster an emotionally safer learning environment in which honest moral dialogue may occur without fear of repercussions. If students cannot learn to apply the principles of ethics actively throughout their clerkships, it will be much harder to do so when they practice independently, and ultimately, patient care will suffer. Conversely, when students and trainees are empowered by their teachers, patient care improves. (shrink)

Purpose Medical students receive a varying amount of training in medical ethics and are expected to navigate clinical ethical dilemmas innately. There is little literature on attempts to navigate ethical dilemmas experienced during early clinical experiences and whether current curricula prepare students for these dilemmas. This study explores the different ethical dilemmas experienced by medical students on their third-year clerkships and analyzes the factors, sources, and resolutions proposed by them.Methods From 2016 to 2018, third-year medical students completed a written assignment (...) to describe, analyze, and reflect on a clinical situation in which they experienced an ethical dilemma. They identified specific ethical dilemmas present, potential preventative and aftermath solutions, and reflected on their professional development from their experience. The research team utilized applied thematic analysis to identify themes and patterns in the data. A thematic matrix was utilized to examine similarities and differences across medical students.Results Of the 162 reflections, 144 (88.9%) students indicated an ethical dilemma that included issues related to autonomy and beneficence. Of these, 116 (71.6%) students found the two ethical principles in direct conflict. Students identified three common sources of this conflict: lack of communication; unclear understanding of clinical policies regarding family authority and psychiatric capacity; and medical negligence. Lastly, students suggested different solutions for dealing with and preventing this conflict.Conclusion Our findings suggest that an overwhelming number of students face ethical challenges when confronted with medical situations that raise conflicts between autonomy and beneficence. Their recommended solutions reveal an appeal among students to have tools and strategies in place to ease the need to make difficult decisions. Medical students might be better served by learning about the complexities of ethical decision-making and the likelihood of experiencing moral distress when they feel an inability to implement what they envision as the best solution. (shrink)

Medical students’ concerns during clinical clerkships may not always be addressed with mentors who work under significant time constraints. This study examined 3rd year students’ survey responses regarding patient encounters to elucidate what may be hidden aspects of their learning environment. We analyzed results to an 18-item survey completed during a required ethics and professionalism course in third-year medicine clerkships over a period of 18 months. The survey covered types of concerns elicited by patient encounters, interactions with mentors about concerns, (...) perceptions of mentors, and level of moral distress. We also examined results of a 7-item evaluation of small group discussions during the study period. 1210 surveys and 195 evaluations constituted the study samples. Students’ concerns related primarily to ethics (36.4%, n = 441) and quality of care (34.5%, n = 418). Concerns had not been raised with a mentor in 535 (44.2%) instances. Students experienced moral distress in connection with 35.4% (n = 324) of cases; this was particularly common when a concern applied to a mentor. Higher levels of moral distress were associated with a lower likelihood of wishing to emulate the mentor (r = -0.27, p <.001). Two thirds of students, 66.9% (n = 107), stated that small group discussions where concerns were discussed lowered their stress levels. We suggest that clinical mentors be made aware of students’ learning needs and that structured discussions be available for students to articulate concerns with peers and facilitators in efforts to uncover elements of the hidden curriculum with the goal of optimizing students’ well-being, learning and professional development. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Who Tells the StoryCindy BitterThirty years later, I do not remember her name, but I definitely remember her face, and this is how I remember her story.She came into the office for her flu shot. She was in her 70s and had a mild case of COPD attributed [End Page 87] to years of exposure to pesticides on the family farm. She said she was trying to stay healthy, (...) as the grandkids were due for a visit, and everyone had gotten a cold after Thanksgiving the year before. I was a sub-intern doing a required rural medicine rotation and diligently did an exam, finding asymptomatic new-onset atrial fibrillation of uncertain duration. We admitted her to the hospital and started anticoagulation. My attending also ordered a calcium channel blocker to slow her pulse, which was running 90–100 while she was at rest. The attending insisted that it would convert her back to sinus rhythm. The nurses were not experienced with the medication and were uncomfortable giving it. I was pretty sure the calcium channel blocker was not indicated, and a quick check of my pocket manual confirmed the drug would lower her heart rate and maybe her blood pressure but that it would not fix the abnormal rhythm. I refused to administer it. The attending came in, pushed the medication, and returned home. A few minutes later, the patient was struggling to speak. Her pulse fell to in the 30s, and her blood pressure had dropped dangerously low. I asked for the crash cart and calcium, and my attending, then started CPR when she lost her pulse. Half an hour later, my attending called her time of death.Hers was not the first death I'd witnessed, but it was the first time I felt like my patient would have been better off without our interventions. As a medical student hundreds of miles from the main hospital campus, I felt powerless to contradict the attending, and did not know where to turn for support in the moment. I rationalized it by saying that I had not actively contributed to her death by pushing the medication, but I held myself morally culpable for doing the exam and finding an asymptomatic abnormality that started her down that path. I felt I should have known the pathophysiology and medication side effects better, or been more assertive, or called for help.One could argue whether I was suffering from a grief reaction or falling into depression, but I questioned my calling to medicine and seriously considered leaving the field. But I was quite certain that I did not want another patient to be put at risk, or a student to feel cornered into taking actions against their better judgment. After returning to the main hospital, I met with the clerkship director and helped develop a pathway for students to raise safety concerns in real-time. Now I recognize the feeling I experienced as moral injury, but we weren't using that term at the time, or talking about Six Sigma safety, or stopping the line.Ultimately, I continued through medical school and trained as an emergency physician. My prior reverence for my attendings moderated to a healthier respect that had to be earned. I read voraciously, trying to prepare myself for unexpected situations. I became an advocate for patient safety and was an early adopter of shared decision-making. I strive to be a physician who welcomes questions and respects the concerns of all team members. Many of the principles that ground my career in medicine grew out of my exposure to this patient.It was always my least favorite of the tropes common to television medical dramas—the circumstances of the patient-of-the-week illuminated some aspect of our main characters' lives, providing a very important life lesson. I felt it positioned patients to be in service of the physician's aims, using patients as a means to our ends, when we should be using our knowledge and experience to further the patient's goals. Very un-Kantian, in addition to transgressing against multiple other philosophers and medical ethicists. As medicine learns more about the power of... (shrink)

The essays in this special issue of HEC Forum provide reflections that make explicit the implicit anthropology that our current pandemic has brought but which in the medical ethics literature around COVID-19 has to a great extent ignored. Three of the essays are clearly “journalistic” as a literary genre: one by a hospital chaplain, one by a medical student in her pre-clinical years, and one by a fourth-year medical student who reports her experience as she completed her undergraduate clerkships and (...) applied for positions in graduate medical education. Other essays explore the pandemic from historical, sociological, and economic perspectives, particularly how triage policies have been found to be largely blind to structural healthcare disparities, while simultaneously unable to appropriately address those disparities. Central issues that need to be addressed in triage are not just whether a utilitarian response is the most just response, but what exactly is the greatest good for the greatest number? Together, the essays in this special issue of HEC Forum create a call for a more anthropological approach to understanding health and healthcare. The narrow approach of viewing health as resulting primarily from healthcare will continue to hinder advances and perpetuate disparities. Health outcomes result from a complex interaction of various social, economic, cultural, historical, and political factors. Advancing healthcare requires contextualizing the health of populations amongst these factors. The COVID-19 pandemic has made us keenly aware of how interdependent our health as a society can be. (shrink)

Examining a fragment of interaction that occurred during a surgery at a teaching hospital, we explore how particular instructed experiences are produced for two trainees, a surgeon in the residency program and a medical student in a surgical clerkship. We are concerned with what is produced as learnable in each case. Stated slightly differently, we are interested in the ways in which the attending surgeon uses demonstrations as instruction and the ways in which recipients of that instruction, in this (...) case the resident and the clerk, respond with enactments of those demonstrated actions. The recipients of this kind of instruction participate in a form of experiential learning in which they enact their own versions of the instructor’s demonstrated actions to be observed and assessed by the instructor. These enactments provide learners with experiential access to the instructor’s demonstrated actions. They are designed to be experiences that learners may draw upon to make experientially warranted claims at some later time. (shrink)

Background: Medical education literature suggests that ethics education should be learner-centered and problem-based rather than theory-based. Team-based learning is an appropriate method for this suggestion. However, its effectiveness was not investigated enough in medical ethics education. Research question: Is team-based learning effective in medical ethics education in terms of knowledge retention, in-class learner engagement, and learner reactions? Research design: This was a prospective controlled follow-up study. We changed lecture with team-based learning method to teach four topics in a 2-week medical (...) ethics clerkship, while the remaining topics were taught by lectures. For comparison, we formed team-based learning and lecture groups, in which the students and instructor are the same, but the topics and teaching methodologies are different. We determined in-class learner engagement by direct observation and student satisfaction by feedback forms. Student success for team-based learning and lecture topics in the end-of-clerkship exam and two retention tests performed 1 year and 2 years later were compared. Ethical considerations: Ethical approval for the study was granted by Akdeniz University Board of Ethics on Noninvasive Clinical Human Studies Ethics committee. Findings: Short-term knowledge retention did not differ; however, team-based learning was found superior to lecture at long-term retention tests. Student satisfaction was high with team-based learning and in-class engagement was better in team-based learning sessions. Discussion: Our results on learner engagement and satisfaction with team-based learning were similar to those of previous reports. However, knowledge retention results in our study were contrary to literature. The reason might be the fact that students prepared for the end-of-clerkship pass/fail exam (short term) regardless of the teaching method. But, at long-term retention tests, they did not prepare for the exam and answered the questions just using the knowledge retained in their memories. Conclusion: Our findings suggest that team-based learning is a better alternative to lecture to teach ethics in medical education. (shrink)

Ms. B. was a 70-year-old woman who presented with a chief complaint of “my belly got puffy.” She noted that her waistband got progressively tighter as her abdomen swelled up on the month prior to her admission. Although not painful, the swelling caused considerable discomfort and anorexia.Ms. B. was a 70-year-old woman who presented with a chief complaint of “my belly got puffy.” She noted that her waistband got progressively tighter as her abdomen swelled up on the month prior to (...) her admission. Although not painful, the swelling caused considerable discomfort and anorexia.Ms. B. had come to the university hospital by referral from her primary care doctor. She was my first patient on my junior clerkship in internal medicine, a specialty I was particularly interested in going into. It is a rare opportunity for a medical student to pick up a mystery case. Ms. B. had come to us without a diagnosis. (shrink)

Resumen: En este artículo propongo una lectura del cuerpo humano como “efecto” de heterogéneas y múltiples prácticas, como la escribanía, la catequesis, la violencia física, el “mito literario” del conquistador y el “mito del fin de las antiguas culturas”. Planteo que dichas prácticas están articuladas con lo que he llamado “dispositivo expedición-conquista”, cuyo papel más importante es el de configurar las representaciones antagónicas del cuerpo entre el conquistador y el indígena en la conquista, de modo particular en México, en tiempos (...) de Hernán Cortés y Moctezuma.: In this article I propose a reading of the body as “effect” of heterogeneous and multiple practices, such as the clerkship, catechesis, physical violence, “literary myth” of the conqueror and the “myth of the end of the ancient cultures”. I argue that such practices are articulated with what I have called “expedition-conquest device” which plays the role of the antagonistic set representations of the body between the conqueror and the conquered indigenous in a particular way in Mexico, in times of Hernán Cortés and Moctezuma. (shrink)

In addition to being a means of communication between people, writing is the only way of recording government affairs. Writing has an important place in the preservation of knowledge and its transmission to future generations. Writing is an activity that occurs through processing meaningful words on a certain surface with a pointed object. As understood from the archaeological data, the first examples of writing were created by engraving on a clay tablet with a pointed object. Throughout history, people have discovered (...) and developed different writing materials depending on geographical and economic conditions. Writing has developed and become widespread in the early Islamic history in a way that serves political, religious and social purposes. The tradition of keeping records, which began at a simple level in the early periods of Islamic history, reached an advanced level as a result of interaction with other civilizations during the Umayyad and Abbasid periods. On the other hand, new writing styles have emerged due to aesthetic concerns. The writing culture, which was shaped depending on the administrative life, was soon reflected in the class that was engaged in science and art. Depending on these developments, writing materials have diversified. In this article, the writing materials used by the clerks working in state institutions in the first two centuries of the Abbasids were tried to be illuminated in the light of historical data. (shrink)

In addition to being a means of communication between people, writing is the only way of recording government affairs. Writing has an important place in the preservation of knowledge and its transmission to future generations. Writing is an activity that occurs through processing meaningful words on a certain surface with a pointed object. As understood from the archaeological data, the first examples of writing were created by engraving on a clay tablet with a pointed object. Throughout history, people have discovered (...) and developed different writing materials depending on geographical and economic conditions. Writing has developed and become widespread in the early Islamic history in a way that serves political, religious and social purposes. The tradition of keeping records, which began at a simple level in the early periods of Islamic history, reached an advanced level as a result of interaction with other civilizations during the Umayyad and Abbasid periods. On the other hand, new writing styles have emerged due to aesthetic concerns. The writing culture, which was shaped depending on the administrative life, was soon reflected in the class that was engaged in science and art. Depending on these developments, writing materials have diversified. In this article, the writing materials used by the clerks working in state institutions in the first two centuries of the Abbasids (132-334/750-945) were tried to be illuminated in the light of historical data. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Grieving the Loss of What Medicine Was Supposed to BeKaterina V. LiongI attended a conference this year. The timing was less than ideal because it was held the weekend before the Internal Medicine clerkship exam. But as with all things, especially during medical school, there is never a "right time" to be doing anything. It was fortunate that I attended the conference anyway because I met an incredible (...) doctor there. She had given a talk called "The Myth of Physician Wellness," and somewhere in our lengthy discussion, she asked me this:"Have you ever considered that since entering medical school, you've never been able to stop and really grieve the loss of what you thought medicine would be?"I am writing this in the downtime during my surgery rotation, regretting that I didn't wait until I got home to fully feel the feelings of writing this because I cannot cry here in front of others. At the same time, I feel guilty spending time writing at all; I should instead be doing UWorld practice questions for my upcoming exam. I can feel it in my body, the feeling of being plugged up—I have allowed tears to leak out too many times this year.The first time was in Internal Medicine, after seeing an elderly patient with a terminal rectal cancer that was so far along you could see it grossly. The bulging mass was so obvious during the patient's digital rectal exam that the senior resident was able to take off his still-clean gloves mere seconds after putting them on. The patient had come in for abdominal pain and difficulty defacating; the [End Page E20] only management he'd been able to receive for his known cancer was multiple hospitalizations in the last few months for emergency blood transfusions when his Hemoglobin level, indicating blood loss from the cancer, got too low. As I was taught to do, I gave a summary statement: "So you're here because you had a primary care appointment for a regular checkup, but they wouldn't see you because they didn't take your insurance? And they sent you to the county hospital, but even though they take uninsured patients, you are technically insured, just under a terrible plan … so they transferred you here. Is that right?" Unfortunately, the man's sí of affirmation was enough to make me lose composure, and I had to step out to let the resident finish the interview.After that, all it takes recently for the tears to well up is for an attending to pull me aside for feedback and ask, "How is third year going for you?" or even "What do you feel you've done well?"I almost wonder if holding in tears is like constipation. In medical school, we learn that sometimes what we think is diarrhea in patients is actually constipation—the stool is so impacted that the only thing that can leak past the plug is liquid. We see the leakage and first interpret that as diarrhea. I have to wonder if people interpret the same about me—emotional lability? Or is my inability to prevent the tears from leaking out simply a product of all the plugging up I have been doing all along? My inability to properly grieve the loss of what medicine was going to be? Maybe the first step in processing that loss is identifying it:I thought medicine meant caring for patients. Why am I going through 7+ years of training if insurance companies are allowed to undermine us so easily?I thought medicine meant connecting with patients. Why am I spending 30 minutes seeing my patients and 2 hours writing notes?I thought medicine meant leadership. Why are others bypassing two-thirds of my time in training and ending up with almost the same job … but the only "leadership" left is that their liability falls on physicians?I thought one must be well to take care of others. Why are students working all day and studying all night, residents too overworked to take a lunch break, and attendings made to work while visibly sick and diaphoretic?I thought... (shrink)

Background: The ethical challenges faced by undergraduate nursing students and nurses may lead to moral distress, negatively affecting learning capacity and self-confidence and potentially influencing the quality of patient care. Objective: To examine the state of knowledge regarding the moral distress among undergraduate nursing students during clinical practice. Methods: This scoping review followed JBI guidelines. First, the LILACS, Web of Science, Scopus, CINAHL, PubMed/MEDLINE, PsycINFO, Embase, and ProQuest databases were consulted. Next, the reference lists of the studies included in the (...) sample were checked. Studies exploring moral distress among undergraduate nursing students during clinical practice were included regardless of language or date of publication. Two independent reviewers simultaneously selected the studies. Results: The sample included 12 articles with different research designs. Three conditions that trigger moral distress among undergraduate nursing students emerged: Interpersonal relationships between students and preceptors/supervisors and multidisciplinary teams; interpersonal relationships between students and patients; and the relationship between students and health services. Conclusions: This review identified the various circumstances that lead to moral distress among undergraduate nursing students. Therefore, these results highlight the importance of preventing moral distress in this group through teaching, especially before students begin their clinical practices. (shrink)