In this thesis it is argued that the migration of ideas and personnel from Britain to colonial Australia resulted in the reproduction of two distinctive medical archetypes, namely, the soldier/saviour and the generalist (family) physician and surgeon. These have been both conceptualised as” ideal type” carriers or expediters of two rival forms of medical professionalism. They each emerged in the ‘modern’ era as institutional products of distinctive educational processes and work practices available for doctors in 19th and 20th century Britain and Australia. While Freidson (1988) asserts one of the problems of dealing with studies of professionalism is that researchers have failed to clearly define work patterns, he could be seen as being close to Foucault (1973) whose emphasis was on the different social spaces in which practitioners worked. I show firstly that the career of the ‘imperial’ army medical officer was revived in the 19th century so that in colonial contexts they could alternate between military and civilian servicing, especially as administrators and managers in public office. The soldier/saviour was also associated with the 19th century revival of Masonic and quasi-Masonic military and religious orders, consecrated by royal sovereigns and exported to Australia. In contrast, the Scottish pedagogues and other generalist doctors coming to Australia from Britain were influenced by Edinburgh University’s Medical Faculty’s humanist traditions and design of the “modern” medical curriculum producing the generalist physician and surgeon who met community needs. Within wider imperial social relations, these generalist doctors were looked upon as ‘dissenting’ or counter-hegemonic. The aim of this thesis is to examine these archetypes in terms of their characteristics of rationalisation to analyse and understand their professional differences historically as well as in the contemporary period. The significance is that one does not often come across studies which specifically look at doctors within the same society in such terms. Furthermore, by locating them within wider hegemonic and counter-hegemonic social relations, links between ideas about medical professionalism and issues of human rights become evident. This follows the World Health Organization’s directives to treat health or medical issues and human rights as a cross-cutting research activity. To my knowledge, no study has been undertaken in Australia of the background and impact of these different traditions.

In this thesis it is argued that the migration of ideas and personnel from Britain to colonial Australia resulted in the reproduction of two distinctive medical archetypes, namely, the soldier/saviour and the generalist (family) physician and surgeon. These have been both conceptualised as” ideal type” carriers or expediters of two rival forms of medical professionalism. They each emerged in the ‘modern’ era as institutional products of distinctive educational processes and work practices available for doctors in 19th and 20th century Britain and Australia. While Freidson (1988) asserts one of the problems of dealing with studies of professionalism is that researchers have failed to clearly define work patterns, he could be seen as being close to Foucault (1973) whose emphasis was on the different social spaces in which practitioners worked. I show firstly that the career of the ‘imperial’ army medical officer was revived in the 19th century so that in colonial contexts they could alternate between military and civilian servicing, especially as administrators and managers in public office. The soldier/saviour was also associated with the 19th century revival of Masonic and quasi-Masonic military and religious orders, consecrated by royal sovereigns and exported to Australia. In contrast, the Scottish pedagogues and other generalist doctors coming to Australia from Britain were influenced by Edinburgh University’s Medical Faculty’s humanist traditions and design of the “modern” medical curriculum producing the generalist physician and surgeon who met community needs. Within wider imperial social relations, these generalist doctors were looked upon as ‘dissenting’ or counter-hegemonic. The aim of this thesis is to examine these archetypes in terms of their characteristics of rationalisation to analyse and understand their professional differences historically as well as in the contemporary period. The significance is that one does not often come across studies which specifically look at doctors within the same society in such terms. Furthermore, by locating them within wider hegemonic and counter-hegemonic social relations, links between ideas about medical professionalism and issues of human rights become evident. This follows the World Health Organization’s directives to treat health or medical issues and human rights as a cross-cutting research activity. To my knowledge, no study has been undertaken in Australia of the background and impact of these different traditions.

Medical educators, clinical trainers, and professional organizations that have responded to the need to humanize medicine have not explored prospects for affective development in distance education. In this dissertation, the author explored narrative as an affective learning technique. Medical fiction, lay exposition, autobiography and other written forms of patient narratives, as well as multimedia presentations, movies, music, song, and visual arts were explored and analyzed for use in teaching medical professionalism to online health science students. A collection of narratives and learning activities for teaching medical professionalism in an online class were presented. Finally, a comparison study evaluated the use of narrative medicine to foster professional development in an online class. The use of narrative to introduce professionalism and help online students internalize the humanistic values of empathy and compassion was grounded in affective theories of moral development. Quantitative evaluation of medical professionalism was performed using the Jefferson Scale of Physician Empathy (JSPE), a psychometrically sound instrument designed to measure empathy in the context of patient care. Comparisons of mean changes in empathy suggest that the treatment group experienced significant changes in total empathy, reflected by increased scores in all elements of the JSPE. These results were validated by a qualitative review of student discussion posts, course evaluations, and instructor feedback. The goal was to explore affective development and the educational value that narrative brings to teaching medical professionalism in the online class. The study helped to clarify the role of narrative in transformative learning. The implication is that online students can benefit from exposure to narrative. The relationship between narrative and medical professionalism may have applications for educational theory, medical and allied health practice, public policy, and future research.

This thesis outlines a study into institutional change analysing how certain senior individuals, called opinion leaders, were able to achieve change within the strongly institutionalized environment of medical education. It is situated in the complex and contested context of the English National Health Service, which for more than 60 years has seen numerous managerial, organizational, political and professional changes, which have impacted upon the roles and relationships of medical professionals, managers and government. Adopting a retrospective case study approach, the research centres on the specific case of the Enhancing Engagement in Medical Leadership (EEML) project, which had national-level sponsorship and status, directly involving a multitude of senior NHS bodies, representatives and individuals, to embed leadership and management training into medical curricula. Medical curricula are a mediated result of cultural, social, political and economic forces (Kuper and D’Eon, 2011) rooted in the construction of professional identity and transformation from lay person to professional. Prior to this project, there had been limited attempts to engage the medical profession in leadership and management conspicuously through the curriculum, because of the difficulty of including new content into already crowded specialty curricula, given the constraints of time and resources for medical training. Using conceptual insights into agency in institutional theory, such as institutional work (Lawrence and Suddaby, 2006) and institutional entrepreneurship (DiMaggio, 1988); practice theory (Feldman and Orlikowski, 2011; Nicolini, 2012); social position (Battilana, 2011) and capital (Lockett et al., 2014; Bourdieu, 1986), this study explores how project members enacted change within medical education. It analyses the processes involved in their actions and practices and establishes how this case furthers understanding of strongly institutionalized environments. Interviews were conducted with members of the EEML project team and steering group, many of whom had positions of influence and status in other relevant organizations in this field. In addition, a review of documentary data encompassing published and non-published project materials was undertaken. An open coding and thematic analysis approach was taken to gain deeper insight into the interview data, whilst the documentary evidence was used to confirm and support the interview analysis. This case study research reveals that contextual and environmental conditions, as well as exogenous shocks and endogenous motivation led to this change initiative occurring. Routine and recognised ‘practices’ resulted in significant change through embedding the Medical Leadership Competency Framework (MLCF) into contested medical curricula space. Opinion leaders were able, with other project members, to adopt an approach to change, understanding the prevailing conditions, identifying the project’s purpose and committing to an emerging form of practice known as ‘mirroring’. Moreover, this study explores how opinion leaders achieved change through making use of theirs’ and others’ capital resources to form a cross-field collective capital, known as system capital. Using this, they adopted a disposition in their practice beyond professions known as system centrism.

Indiana University-Purdue University Indianapolis (IUPUI) / Medical education researchers have long been interested in understanding medical professional identity formation and its implications for the healthcare system. Various theories have been proposed to explain identity formation. Among them, Foucault’s discourse theory maintains that it is the discourse of medicine that constitutes medical professional identities. This study deployed a Foucauldian archaeological methodology to analyze the structure of modern medical discourse and establish links between discourse and professional identity formation in medical students. A total of forty-six medical students at Indiana University School of Medicine participated in either individual or focus group interviews. Direct observation of the clinical and educational settings was also performed, which resulted in additional textual data in the form of fieldnotes. Archaeological analysis of discourse was undertaken in three levels of the statements, the discursive elements, and the discursive rules and relations. Results entailed a detailed depiction of the structure of medical discourse including discursive objects and modes of enunciation, discursive concepts, and theoretical strategies related to each object. Discursive objects are things that are talked about in modern medical discourse. This study identified four discursive objects as disease and treatment, the doctor, the human body, and the sick person. Modes of enunciation are the different ways in which people talk about objects of medicine, whereas concepts consist of the notions people draw from when talking about objects of medicine. Theoretical strategies indicate certain positions that people take in relation to the objects of medicine. Rules of formation and conditions of existence for each discursive element were also established. Since Identities are entrenched through language and interaction, developing a systematic understanding of the structure of medical discourse will shed new light on medical professional identity formation. Results of this study also have profound implications for teaching professionalism and medical humanities in medical curricula. Furthermore, as a research methodology used for the first time in medical education, archaeology not only opens new territories to be explored by future research, it also provides an entirely new way to look at them.

In un contesto in cui il coinvolgimento e la partecipazione dei consumatori/clienti di prestazioni sanitarie è oggi più che mai all’ordine del giorno, il concetto di “patient engagement” si è sempre più imposto nella letteratura scientifica e manageriale come call to action in risposta alle sfide epidemiologiche – legate all’aumento della cronicità – ed economiche – connesse all’aumento dei costi sanitari e alla riduzione delle risorse disponibili - a cui i sistemi sanitari contemporanei devono necessariamente rispondere per evitare il collasso. Per ciò, a fronte di una letteratura sul tema ancora parziale e frammentata, definire il concetto di “patient engagement” e le sue implicazioni a vari livelli diviene cruciale per passare da una dichiarazione di intenti ad una concreta strategia di azioni volte a promuoverlo. Alla luce di queste premesse, il progetto di ricerca ambisce a rispondere ad una necessità fondativa sia da un punto di vista teroico che empirico di questo concetto e ad evidenziare possibili linee di sviluppo e ricadute applicative per una rinnovata professionalizzazione dei clinici che devono oggi riadattare le proprie pratiche professionali e ripensare alla propria identità in funzione di un paziente sempre più attivo e partecipe rispetto alle scelte legate alla gestione della propria salute. / The expectancy of patient living with chronic disease has improved significantly in the recent years due to advances in medical sciences. To address the burden of this growing demand of care, patient engagement is considered crucial as it contributes to improve health outcomes and control healthcare costs. However, many gaps still exist for its implementation starting from the lack of a shared definition and shared guidelines for medical practice based on the direct patients' care experience. In the light of this premises this dissertation will propose a sequential research design generally aimed at improving the knowledge and understanding of patient engagement and its implications for the medical practice and professionalism. To answer the overall aim of this thesis both literature reviews and qualitative methodology were used. Chapter 1 was aimed to set scene and give the readers an overview of the global cultural and societal scenario that justifies the need to deal with the topic of patient engagement. Chapter 2 and 3 consist in in-depth literature reviews aimed at shading light on the concepts featuring the participatory medicine movement and, more specifically, the one of patient engagement. An in-depth qualitative study according to the grounded theory principles was conducted and reported in chapter 4 and was aimed at deepening the heart failure patient’s perspective towards engagement in their care in order to build and experience-based model of this phenomenon. The last two chapters, based on the insights emerged from both the literature analysis and the grounded theory study, were aimed at discussing the implications of patient engagement for the clinical decision making process (chapter 5), and for training health professionals in patient engagement strategies and improving the effectiveness of their communication and relational habits with this aim (chapter 6).

Submitted by Izabel Franco (izabel-franco@ufscar.br) on 2016-10-25T17:31:05Z No. of bitstreams: 1 TeseFOA.pdf: 2216735 bytes, checksum: c9e58bb11474ae5927196546b5d09b28 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-11-08T19:14:08Z (GMT) No. of bitstreams: 1 TeseFOA.pdf: 2216735 bytes, checksum: c9e58bb11474ae5927196546b5d09b28 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-11-08T19:14:16Z (GMT) No. of bitstreams: 1 TeseFOA.pdf: 2216735 bytes, checksum: c9e58bb11474ae5927196546b5d09b28 (MD5) / Made available in DSpace on 2016-11-08T19:14:23Z (GMT). No. of bitstreams: 1 TeseFOA.pdf: 2216735 bytes, checksum: c9e58bb11474ae5927196546b5d09b28 (MD5) Previous issue date: 2016-06-06 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / This research analyzed, in the local power of São Carlos (SP), the connections between medical professionalism, urban and industrial development and the political centralization of the Brazilian nation state, which conditioned specific waves of interiorization of medical professionalism, as well as particular professional rip current. The focus is oriented to the period of 1889 to 1988, when have occurred three waves of interiorization of medical professionalism and two professional rip currents. The first wave (1889-1930) happened at the beginning of the Republic, in the context of a decentralized political system (coronelismo) and of a parallel growth of the São Carlos’ coffee production. This allowed the first impulse of the local urban economy, the emergence of some new public health and medical assistance services and the establishment of an initial but effective medical market. Some new physicians arrived in the locality, whose specialization was commonly in general practice. Very soon, these professionals were integrated into the local social stratification, working as liberal professionals and in the Santa Casa de Misericórdia de São Carlos. The second wave (1948-1966) was characterized by the local effects of the political centralization of the state and its new role in the Brazilian urban and industrial development as well as in the organization of a national health system. The preview alliance between physicians and the São Carlos’ coffee elite became less important than in the past. The central state became more powerful and begun to compete with the local elites in the countryside of Brazil. This is the moment of the medical reaction to the socialization of medicine, when local physicians create the Sociedade Médica de São Carlos. In this period, there was an important historical trend of young local citizens (born in São Carlos), who went out to study medicine, but returning back later to work as physicians. As their antecessors, these young professional worked in the general practice. Otherwise, the third wave (1970-1988) arose since the reaction of physicians against some problems with the medical assistance of the state pension system. Indeed, the period also verified the organization of a new hospital, Casa de Saúde e Maternidade São Carlos, as well as the construction of a new building for Santa Casa de Misericórdia. São Carlos observed a relevant urban and industrial growth, paralleled by the increase of groups of industrial workers and urban middle classes. Aside the interiorization of medical faculties, professionals who have studied in these new faculties arrived São Carlos, not to act in general practice, but as specialists. Since a tied and smaller medical market as well as the condition of exporter of patients, São Carlos became polo of attraction for professionals and patients from other localities. This favored the creation and expansion of the UNIMED São Carlos, which responded to the higher demand for local medical services, the crisis in the medical assistance of the pension system and new obstacles from the market of private medical group sector. Both UFSCar and USP São Carlos intertwined with the growth of the locality, as well as with physicians, in order to increase the hospital services of São Carlos. As professional rip currents, between the first and the second waves, and between this one and the third wave, some reverse social processes acted historically in an opposite way in relation to each mentioned wave, favoring the occurrence of the next one. At the end of this period, emerged a combination of historical factors, such as: increase of the medical group sector (specially the UNIMED); the worst of the state medical assistance; political movements of physicians; emergence of the collective health; different role of industries in the Brazilian development; democratization; and decentralization of the national health system, which led to the creation of SUS. / Este trabalho analisou, no contexto do poder local de São Carlos (SP), as conexões entre o profissionalismo médico, o desenvolvimento urbano-industrial e a centralização política de Estado brasileiro, o que condicionou específicas ondas de interiorização do profissionalismo médico, assim como certas correntes profissionais de retorno. O foco do trabalho dirigiu-se para a investigação dessas questões no período de 1889 e 1988, quando se verificaram três ondas de interiorização do profissionalismo médico e duas correntes profissionais de retorno. A primeira onda (1889-1930) aconteceu em meio ao início da República, à relativa descentralização política do coronelismo e ao paralelo crescimento da economia cafeeira paulista e, em particular, por sua pujança em São Carlos, que provocou o primeiro impulso da economia urbana local, a criação dos primeiros serviços de saúde pública e assistência médica e pelo estabelecimento de um inicial, mas efetivo mercado médico local. Houve a chegada dos primeiros médicos a localidade, com perfil generalista e que logo se inseriram na estratificação social local. Neste caso, predominou a atividade médica liberal e junto à Santa Casa de Misericórdia. A segunda onda (1948-1966) foi caracterizada pela centralização política do Estado, seu papel no desenvolvimento urbano-industrial e no sistema de saúde nacional. Diante dessas mudanças, as anteriores relações de aliança dos médicos com, especialmente, a elite agrária local, deixam de ser tão decisivas, já que o Estado central passou a rivalizar com o poder das elites locais. Este é o momento de uma reação médica à socialização da medicina, a partir da criação da Sociedade Médica de São Carlos. Houve um movimento importante de filhos de famílias são-carlenses que saíram do município para estudar medicina, voltando a São Carlos para desenvolver suas carreiras. Os profissionais ainda apresentam o predomínio do perfil generalista. Já a terceira onda (1970-1988) decorreu, em parte, da reação médica frente aos problemas da assistência médica previdenciária. Este período foi marcado pelo surgimento da Casa de Saúde e Maternidade São Carlos, assim como pela ampliação da Santa Casa de Misericórdia, em meio a um maior desenvolvimento industrial e urbano local, com ampliação de setores operários e de classes médias urbanas. Favorecido ainda pela interiorização de cursos de medicina, este período verifica a chegada de novos profissionais especialistas formados em cursos mais novos. De um mercado menor, fechado e exportador de pacientes, São Carlos tornou-se polo de atração de profissionais e pacientes de outras localidades. Isso impulsionou a criação e expansão da UNIMED São Carlos, em resposta a maior demanda por serviços médicos locais, à crescente crise da assistência médica previdenciária e às pressões de certos setores de convênios médicos privados. No período, a UFSCar e a USP São Carlos se articularam ao crescimento do município, envolvendo-se com outros grupos locais e médicos e em melhorias no sistema hospitalar são-carlense. Como correntes profissionais de retorno, entre a primeira e a segunda ondas, e entre a segunda e a terceira, observou-se a ocorrência de fatores sociais que, enquanto contra processos sociais, arrefeceram, relativamente, cada prévio movimento de onda de interiorização, favorecendo a emergência, em cada caso, de uma nova ondas de interiorização. No final do período analisado, ainda se nota o crescimento dos convênios médicos, em especial da UNIMED São Carlos, bem como piora na assistência médica estatal, movimentos médicos de reinvindicação trabalhista e movimentos de grupos envolvidos com a ascensão da saúde coletiva, que buscavam a reforma do sistema nacional de saúde, já no contexto de crise do desenvolvimento urbano-industrial, de redemocratização do país pós-ditadura militar e de ações descentralizadoras da área da saúde, que desembocaram na emergência do SUS.

Ο ιατρός καλείται να ανταποκριθεί σε ένα ρόλο με διττή σημασία: σε αυτόν του θεραπευτή και σε αυτόν του επαγγελματία. Η σύγχρονη ιατρική εκπαίδευση στοχεύει στην καλλιέργεια στάσεων για τον επαγγελματισμό. Η παρούσα εργασία πραγματεύεται το ζήτημα της διαμόρφωσης της επαγγελματικής ταυτότητας των προπτυχιακών φοιτητών του Ιατρικού Τμήματος του Πανεπιστημίου Πατρών. Πιο συγκεκριμένα, διερευνάται το πλαίσιο στο οποίο βιώνεται η ασθένεια, αναγνωρίζεται η ανάγκη παροχής υπηρεσιών υγείας προς την κοινωνία και εξετάζεται η ανάπτυξη του ιατρικού επαγγέλματος. Αρχικά, πραγματοποιείται μια εκτενής εννοιολογική αναφορά στον επαγγελματισμό, όπου βασίζεται και η επαγγελματική ταυτότητα του ιατρού. Ακολούθως, με την εμπειρική έρευνα επιδιώκεται η διερεύνηση των απόψεων και των στάσεων, που αναπτύσσουν οι προπτυχιακοί φοιτητές της εν λόγω Σχολής σχετικά με τις βασικές παραμέτρους διαμόρφωσης της επαγγελματικής τους ταυτότητας. Επιπρόσθετα, εξετάζεται η σύνδεση του Οδηγού Σπουδών του Τμήματος με τα χαρακτηριστικά του επαγγελματισμού και ειδικότερα της ιατρικής ταυτότητας. / Doctors are expected to cope with the roles of both healer and professional. Current guidelines for medical education require students to develop proper attitudes towards professionalism. In this work we explore the theoretical concept of professionalism, concerning the undergraduate students, who attend the Medical School at the University of Patras. In particular, we examine the context in which the disease, the health service and the medical profession are encountered. Empirical study is carried out in order to identify the core elements of the undergraduate students regarding medical identity. In the theoretical part, we extensively examine the notion of professionalism, in which the formation of medical identity is based on. In the empirical part of the dissertation, we seek to reveal the attitudes which are related to medical professionalism, according to students’ beliefs. Furthermore, we examine the connection among the Medical School’s curriculum, the characteristics of professionalism and the elements, which are being identified in medical identity’s definition.