Critical incidents experienced by medicine interns in pandemics: A qualitative study at a South American medical school

Critical incidents experienced by medicine interns in pandemics: A qualitative study at a South American medical school | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Critical incidents experienced by medicine interns in pandemics: A qualitative study at a South American medical school Soledad Armijo, Marcela Castillo Franzoy, Valentina Fuentes Lombardo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4266187/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Critical Incidents (CI) during clinical practice can provide relevant information regarding students' stress, weaknesses in the teaching process, psychological safety, and the healthcare system. This study aimed to determine the elements considered by students to be CI during the COVID-19 pandemic in Chile. Methods This qualitative study was conducted on a sample of voluntary medical interns. Data production techniques were documentary analysis of the CI described in portfolios and two focus groups. Two researchers performed a reflexive thematic analysis of the CI and the focus groups. The Institutional Ethics Committee approved the research protocol. Results Twenty-four interns voluntarily participated. The coding process identified 22 definitive codes that were synthesized into nine subthemes and three themes that described types of CIs, factors that influence them, and effects generated by CI. The main findings were that CI were mainly related to non-Covid pathologies, causing negative emotions. They were cases of high biopsychosocial complexity, in which the ethical dimension of difficult decisions or "questionable" or "unacceptable" behaviors emerges. Some CI were linked to the human relationship between students and teachers or between the health team, or communication with patients and their families. Elements related to hospital organization were less described. The adaptations, learning, and reflections referred to the intern's professional role, ethics, communication skills, and self-care; and were produced autonomously, with little teaching support. Discussion CI analysis allows interns to reflect and imagine how to bring learnings into their future practice. The primary emotions associated with CI were negative, and their adaptations were autonomous. The school could improve with more teacher support and better role models to manage CI and support the interns' mental health better. One important topic to address is if the teachers are really available and prepared to be supportive, or if they are part of the causes of the CI. Medical Student Critical Incident Technic COVID-19 Mental Health Psychological Safety Figures Figure 1 Introduction Critical Incidents (CI) analysis in medical education began as an alternative to teaching evaluation surveys. It made it possible to identify factors associated with good teaching aimed at medical students, teachers' interpersonal behavior, planning, preparation, and the ability to lead the session well. [ 1 ] Another approach was using the CI to reflect and evaluate the patient's story [ 2 ] from the perspective of preclinical cycle students, interns, residents, and practicing physicians, identifying that the concept of CI was associated with different areas or categories throughout the training process and in the professional practice. Also, the CI technique was used to define specific aspects of the curriculum, such as professionalism, [ 3 ] or to explore errors in internship practices. [ 4 ] In recent years, the report and analysis of CI have been used to address the inclusion of minorities, [ 5 ] stress, [ 6 ] and negative experiences in students, [ 7 ] the teaching of professionalism, [ 8 ] and interprofessional training. [ 9 ] Likewise, using teaching guides based on CI analysis has been proposed to contain microaggressions in the context of teaching in clinical settings. [ 10 ] Likewise, factors dependent on the health system emerge that generate disparity or inequities and are linked to the analysis of CIs from the health systems perspective. [ 11 ] Critical health incidents are usually caused by multiple overlapping failures rather than single or individual failures. Their analysis is part of the continuous improvement process and clinical risk reduction. One of the barriers to the success of this strategy for confronting and analyzing CIs in the United States is the need for more commitment from doctors. [ 12 ] The teaching of CI analysis needs to be more emphasized at the undergraduate level. Incorporating the report of these incidents from students can improve the psychological safety of clinical practices and generate qualitative improvements in their programs. [ 13 ] CI interviews exploring the challenges of caring for patients at the end of life in junior doctors and interns in Ireland show a lack of knowledge, preparedness, and support associated with a feeling of failure. [ 14 ] CI about night-time experience in medicine and pediatric interns shows that the shifts provide rich experiential learning and that interns require support to optimize workplace learning. [ 15 ] CI observation scales have been used in simulations by interdisciplinary health teams to address patient safety elements. [ 16 ] On the other hand, in the initial analysis of the pandemic scenario, some authors identified the institutional responsibility of students since they are not essential health team workers [ 17 ] . It was necessary to adapt clinical teaching to the needs of students in the context of a pandemic, recommending the retirement of the students from clinical practice in this complex scenario. [ 18 , 19 ] Recently CANMED experts have analyzed the effect of the Covid-19 pandemic on virtual healthcare, [ 20 ] the relevance of humanism in the profession [ 21 , 22 , 23 ] the role of the healthcare industry in the climate crisis and its effect on patients, [ 24 ] the effect of technological innovations on adaptive learning [ 25 , 26 ] and the effects of cognitive load on clinical decision making. [ 27 ] For the Lancet Commission, the current moment offers opportunities and challenges for competency training, interprofessional education, and the use of technology. They analyze the reality of clinical practices and propose a model of foundational, specialized, and integrative competencies for health careers. [ 28 ] The educative meaning of CI has been used to make the student's voice visible in different contexts but has yet to be explored to analyze this voice in a global clinical crisis. In the context of the pandemic, the variables related to clinical teaching, including internships, have undergone great changes. That fact may influence the appearance of CI linked to health care that traditional training has not considered. In that sense, there is a gap in the literature related to how the context in which the training of internships occurs during pandemics may have impacted student learning in their final years of vocational training in South America. This study aims to determine the elements that students consider as part of their CI reports in the context of internship practice during a pandemic in the years 2020–2021 in Chile and identify the adaptation and support they had during this time. Methods Qualitative approach We conducted a reflexive thematic analysis of participants’ critical incidents. Reflexive thematic analysis is an easily accessible and theoretically flexible interpretative approach to qualitative data analysis that facilitates the identification and reflexive analysis of patterns or themes in a given data set [ 29 ] Participants The study was conducted on students who began Internships in 2020 and wrote their portfolios in the second semester of 2021 (July-December). The universe of interns invited to participate was 67. The final sample was defined by the reach of data saturation. Context The study was conducted over 6 months at the Medicine School of Universidad del Desarrollo in Santiago, Chile, a private not-for-profit graduate entry medical school. The preclinical curriculum has five years and includes clinical and simulated practices that provide students with clinical skills and interactions with real patients, standardized patients, simulated patients, and high-fidelity simulations. and provides an academic license. After that, the students begin a two-year internship period, focused on in-hospital and ambulatory care services, where they perform a supervised clinical practice, structured in clinical rotations at public facilities. During the first semester of 2020, these clerkships were modified focusing on the training in adult in-hospital practices, with fewer opportunities for practice in ambulatory care, and the inclusion of Telemedicine practices and research and simulation activities to complement the training and contextualize it to the pandemic context. The assessment system was also modified, adding a portfolio, that includes a CI report. In this CI section of the portfolio, the interns were invited to share a short narrative of a challenging, significant, or disturbing singular event from their practice to reflect on what happened and what adaptations and support they had related to the event, allowing freedom of expression. Sampling strategy, data collection, and analysis Through an informed consent process, the research project participants agreed to have their portfolios analyzed by a research team that did not participate in assessing their internships. The principal researcher (SA) anonymized the CIs extracted from the portfolios before analyzing them. Before conducting the focus groups, the volunteers participated in consent processes guided by the principal researcher (SA). An audio recording of the focus group sessions was left. The focus group consent included authorization for using the audio recordings for the analysis associated with the research. For data analysis, a six-step approach was performed by two researchers (SA, MC). In the first step of data familiarization, the research team read the CIs to identify appropriate information that may be relevant to the research question. In the second step, a codification process was performed, using a predefined codebook based on the literature in an attempt to enhance coding reliability. Given the number of participants, two researchers analyzed the texts independently (MC and SA) manually. The focus group analysis contemplated transcription of the sessions and the same codification process described for the written documents. The coding process was iterative, with three subsequent data revisions. It produced succinct descriptive labels for information relevant to the research question. In a third step, the coded data were reviewed and analyzed to understand how they were combined in terms of shared meanings, and how they formed themes and subthemes. The fourth step was the final revision of the themes, which was named in the fifth step. The sixth step, producing the report, includes the participation of two students (VF and FP) to enrich the interpretation with their perspectives. Ethical considerations The research project was approved by the Institutional Research Ethics Committee of the University (Approved in June 2021). Every participant was part of an informed consent process. Results A voluntary sample of 24 interns agreed to have their portfolios analyzed. Thirteen participated in the focus groups. Six CI texts were coded using the pre-established codebook, finding that 90% of the initial codings matched the predefined categorization system. Two new codes emerged related to the ethical dimension of clinical teaching and the crisis adaptations students establish with their means. The codings of the two researchers using the codebook were 95% agreeable. The coding process identified 22 definitive codes that were synthesized into nine subthemes and three themes that described types of CIs, factors that influence them, and effects generated by CI (Table 1 ). Table 1 Themes, subthemes and definitive codes related to critical indicents during medicine internships in pandemic in Chile. Theme Subtheme Definitive code Causes of CI Negative interpersonal relationships Residents Clinical teachers The healthcare context (non-COVID) Complexity of clinical cases Work overload The COVID context Patients and family communication Factors that influence CI Personal factors Management of emotions Tolerance to uncertainty and frustration Non-technical skills Teaching process Teachers overloaded with clinical work The internship experience Pedagogical potential of CI Health context Typical clinical cases Communication styles Effects generated by CI Emotions Negative is the first response Positive about their contribution Learning Self-reflection after CI About healthcare system Teamwork Adaptations Family support School preparation (simulations) Teachers support Healthcare personnel support and teamwork Below, we describe the codes, subthemes and themes, the reflexive interpretation of their relations (Fig. 1 ) and provide representative student quotes. 1.- Causes of CIs The participants considered that the COVID-19 context influenced their critical event to a greater or lesser extent, independent of the specific characteristics of the incident reported. "What happened to me was not because of the pandemic, but I think it still adds to the pandemic in all cases" Intern3 "My CI did not have much to do with the pandemic, but it took place in a health system collapsed by the pandemic, so you could say that it was related to the pandemic, I do not know if you understand. Intern7 It was possible to categorize three areas or groups of CIs. The most predominant were those related to bad experiences of interpersonal relationships with other health professionals or teachers, and "questionable" or "unacceptable" behavior on the tutors' actions. Another group was concerned with the health context, which operates as a backdrop. The health situation permanently and transversally colors the most critical events. The cases related to the CI were of high biopsychosocial complexity, in which the ethical dimension associated with difficult decisions emerges. "They were more experiential things of the practice concerning the moment the country and the hospital were going through, with the burden that existed and how patients were being handled in general, such as people dying in the corridor or young people dying, situations that were anomalous to the classic medicine we knew. That might be perhaps a little bit more prevalent than the rest, but at that time, there were all kinds of incidents, emotional, family, work, uncertainty in the hospital, there was everything". Intern14 Managing Covid patients and their families is part of some of the CI. In these situations, a high emotional burden is evident, and the assignment of responsibilities forces them to learn quickly and strengthen their autonomy. "Many times, I was the one who had to give information to patients and families who were going to die, so managing families was complex, but it taught me many things. Sometimes they were right and then they were wrong, it was crazy...". Intern20 2.- Personal factors influencing CI The interns state that the personal factors are related to the high emotional demand the pandemic placed on everyone. The vulnerability and sensitivity that prevailed at the worst moment of the crisis influenced critical events related to interpersonal issues and communication with postgraduate residents, teachers, and other health professionals. The experience varies according to the timing of the reported CI. The high demands of care work meant that all those involved found their non-technical skills thresholds altered: empathy, frustration tolerance, and teamwork skills, to name a few. These skills played a key role and needed to be moderated and worked on. "Mine was related to a specific patient, but also how that critical event triggered a response from the health care team and how that ultimately impacted my values". Intern3 In another sense, the high level of uncertainty of the academic times influences, given that the planning of the internships was being constructed according to the evolution of the pandemic in the country. For those interns who were more structured, not knowing precisely what course their training process would take generated uncertainty that was difficult to manage and impacted performance. "I like to have a bit of structure and to know what comes next and to arrive at the internship was to arrive at that part of the career in which you become a doctor, and with the internship one was going to be ready for life and one knew that you started with the electives, and then pediatrics (...) and with my more square mind it was very difficult for me to get on the bandwagon that everything was going to be on the fly". Intern1 3.- Factors in the teaching process The teaching role was somewhat absent during the health crisis since the clinical duties of doctors and health personnel played a critical role and occupied their time and energy. This is understood and justified from the point of view of urgency, even though, in the end, it still affects the learning experience of the interns. "As my incident was at the end of the first wave and everything was stabilizing a bit in the hospital, in my experience, there were teachers, but depending on the rotation within the internship, as one is not always in the same team within the internship, one rotates between teams and in some there is a lot of teaching, they monitor you much more, but in others you are more left out...". Intern8 The interns felt that the approach to the CI changed depending on whether it was experienced at the beginning, during the process, or later in the health crisis. The more advanced the crisis, the more coping tools they feel they have acquired to deal with the difficulties of a new critical event. The interviewees share that the critical event provides much learning, the experiences serve as an example for future situations, and their reporting enriches that learning. "The CI was at the very beginning of the whole period where I wrote the portfolio, so I had to remember the critical incident many times, and it often served me as an example (...) if it happened to me now, maybe I would have more tools to be able to face something like this". Intern1 4.- Health System Incidence Some interviewees refer to the health context, independent of the health crisis. They report incidents that seem familiar to "the life of doctors," responding to a style of communication and negative confrontation that would be typical of the sector and independent of the contingency. "I think that if it happened now, when the pandemic is calmer, it would still have been a CI, because it has more to do with how things are done in health, and with some styles that are very specific to the field and how things work". Intern8 5.- Effects generated by CIs Students express negative emotions such as pain, sadness, grief, or crying, which occur as an immediate reaction to critical events of a clinical or biological nature. Likewise, they express indignation, anger, and frustration when the critical event is linked to situations of coexistence and dealing with the health team and teachers. When the emotions were related to reflection after the critical event, in which the students themselves had managed to adapt, the most frequently described states were motivation, pride, and joy. "This was different, a sepulchral silence and then came the second moment of pain that marked me the most, handing the father his dead baby" (Intern24). Some interns declare to be able to carry out a reflexive activity that generates learning after a CI. They highlight the involvement of their family and adaptation as the predominant feeling. These adaptations were dependent on the student and their close social environment "This made me reflect on the fragility of life, and how it can surprise us negatively when we least expect it" (Intern19). Some interns mentioned that the school provides curricular opportunities to prepare for that crisis. Anticipation with simulations of difficult communication was the most important resource they mentioned. They also consider that connection with some teachers was a positive factor in facing the crisis "I was very grateful to the doctor because if it had not been for her, I would not have been able to understand the reason for the patient's behavior..." (FGXII7 = connection with teacher). In a few cases, the CI provides the opportunity to learn more about the Chilean health system, including clinical protocols or organization of the country. "I learned more about SENAME and the different options that exist in our country, having to evaluate in a "balance" way in which environment the patient would benefit the most". (FGXIV 15 = country organization) The positive elements described concerning the health system were related to the actions and attributes of the personnel and the health team's teamwork. "I spoke to the doctor in charge of the floor, and we managed to get him in to say goodbye" (FGXXIV 23 = Flexibility). Discussion The principal findings in this study were that the CIs were predominantly related to clinical cases of non-COVID pathologies that occurred in a public hospital and caused negative emotions. This is similar to the findings of another study that describes CIs related to negative experiences in students before pandemics [ 7 ] and highlights that the conditions of clinical teaching during internships are complex and independent of the actual crisis. This is an important issue because determines that medical schools should be aware of the existence of moral distress and challenges to psychological safety in clinical settings in our country. When observing the emotional impact described by the students, the role of the family and friends' support they received directly or indirectly stands out, which was considered superior to that received in learning in a normal health situation. This support was superior to that of their peers, clinical tutors, school, or clinical service. This reflects the fact that the majority prefers to vent and take refuge in people outside the internship, as was stated in previous studies in the Latin American context. [ 30 ] Previously, CI has been used to address positively the teaching of professionalism, identifying “ altruism, accountability, duty, excellence, honor and integrity, and respect for others” as part of the conduct of teachers as role models [ 8 ] . That situation is also present in some CI analyzed in this study when the teachers support the students or reflect on the CI. However, in other cases, the interns describe "questionable" or "unacceptable" behavior on the tutors' actions, reflecting the dualism of teachers' role modeling. It has been suggested that teacher training of medical professionals would help to contain this negative role model. However, studies on the training of clinicians in universities in Chile are scarce [ 31 , 32 ] and do not refer to the transfer to practice of the concepts or values transmitted in the training programs. Likewise, using teaching guides based on CI analysis has been proposed to contain microaggressions in the context of teaching in clinical settings [ 10 ] . For us, CI is a useful tool to continue analyzing these complex dimensions of teaching and also a tool to reflect on how to address the difficulties in teaching and learning when role modeling is not precisely ideal. The high demands of care work related to the crisis were an explanation the interns accepted from their teachers. CI analysis has been used to understand the stress in medicine students [ 6 ] . In healthcare education, the studies highlight the excessive exigencies during the formation [ 18 , 33 , 34 ] , exigencies that sometimes surpass the student in terms of the resources available to him/her, the learning opportunities he/she has had, and the level of education he/she is pursuing. [ 35 ] The workload is one of the factors most associated with stress in this group [ 36 ] , and it is only one of the mental health problems they face. Burnout, anxiety, depression, alcohol dependence, and suicidal ideation, are other important problems that affect the students. [ 30 , 37 , 38 , 39 , 40 ] This is complex, given that medical students should learn how to protect the health of others, and for that, it is necessary that they learn to protect their own in formative contexts [ 40 ] , and that the formative contexts allow it. A recent study in Chile concludes that mistreatment is present in a medical school [ 41 ] , showing that the role models of clinical tutors do not always guarantee the psychological safety of interns and that this is a problem in Chile. The interns understood the sense of urgency that the Covid-19 emergency established and valued that their teachers should work on their care activities over teaching activities. In this sense, the high level of uncertainty of the academic times was difficult to manage and could impact performance. The vulnerability and sensitivity that prevailed at the worst moment of the crisis influenced critical events. According to Maini, “Healthcare professionals and students globally are experiencing an increasingly 'VUCA' (volatile, uncertain, complex and ambiguous) healthcare and educational climate” [ 42 ] , and coaching activities are important during their formation in order to allow them to face this complexity and provide better care to their patients, that also experience this complexity. Another strategy proposed to address this VUCA context is Case-Based Education (CBE), which helps the students better understand the patient and families' perspective in this global context. [ 43 ] Reflecting on the critical instances allows students to imagine how to take the learning to future practice. In conclusion, thanks to the analysis developed in this study, the main adaptations that students reported in a reflective and descriptive portfolio in the midst of a pandemic were: the exercise of greater autonomy, the assessment of greater academic flexibility received from medical school as manager of the process and that in a possible future health care crisis, the main hospital for professional practices cannot guarantee organic support for teaching and that a strategy for this to improve would be to have a greater teaching presence or a link preference of students with the best models of professionalism. The role of teachers in the pandemic has been transformed. Tutor and apprentice worked together for a global challenge, they were complicit and together they overcame the natural fear of the unknown. The portfolio seems to show that it is a good way to open up the expression of those emotions with great confidence and achieve new meaning in learning. The interns could understand and measure how the health context influenced their experiences. At the same time, they identify the reflective process of creating a CI as a good way of working on learning from a limiting life experience and not forgetting what it was like to do the internship during the Covid-19 pandemic. A fundamental component of life-long education is empowering students to uphold their purpose and mental well-being. This entails acquiring the skills to harmonize their professional endeavors with non-work-related aspects and cultivating coping mechanisms to manage stress and surmount challenges effectively. [ 15 ] This holds particular significance in their aptitude to adapt to the student's critical events they experienced. As previously indicated, most students sought support from their familial and social circles beyond the confines of medical school, implying the presence of robust networks that aided them in facing adversity and addressing negative emotions. This leads to the presumption that some individuals might have succumbed to the burdens of stress and burnout without a sturdy support system beyond the realm of medical school or clinical service. Consequently, this underscores the imperative role that medical schools and clinical mentors should play as support systems and student confidants. In depicting critical events a few students accentuated the pivotal significance of clinical mentors in their adaptation process, which sheds light on their limited involvement in this specific facet of life-long education. This leads us again to mention the importance of coaching by faculties and clinical mentors in an increasingly VUCA clinical environment, where no one other than the peers and professionals involved can support and help solve current problems faced by health professionals. [ 43 ] One of the strengths of the study is that includes students' perspectives on the data and interpretation, validating the role of formative research initiatives during the curriculum. One of the weaknesses is that the main analysis of the qualitative data was performed by one single researcher, who has research experience but also has some biases that The elements related to the hospital organization, its protocols and processes, and the dynamics of teamwork in the hospital appear in a smaller proportion. It seems that the vision of the interns about CI is far from the healthcare concept, and that is not visible to them that there is a need to analyze this CI from an organizational perspective in order to improve the healthcare process and reduce clinical risk. In that sense, these findings support the idea that physicians can be a barrier to implementing continuous improvement programs. [ 12 ] The health system also changed the teaching process after the pandemic. This idea does not emerge in the CI analysis. In the literature, there are some descriptions of how the changes in health systems define new aspects to consider in the teaching process, such as humanism in the profession [ 21 , 22 , 35 ] or the effects of cognitive load on clinical decision-making [ 7 ] . Further research could examine these elements from the interns' perspectives in our country. Some unanswered questions are related to the educational effect on patient safety of CI analysis, which has not yet been analyzed or reported worldwide. The recognition of the security elements linked to the analysis of critical health incidents, from the perspective of medical students, can provide useful guidelines to include these concepts and elements in the curriculum of other professionals of the health team who exercise leadership roles or in the training of other professions as lawyers or engineers who are linked to legal processes, administration or health planning. Conclusions CI analysis allows interns to reflect and imagine how to bring learnings into their future practice. The primary emotions associated with CI were negative, and their adaptations were autonomous. The school could improve with more teacher support and better role models to manage CI and support the interns' mental health better. One important topic to address is if the teachers are really available and prepared to be supportive, or if they are part of the causes of the CI. This article is important because it includes an actual perspective of medicine interns' experiences during internships. The interns reflect on some conditions that transcend the pandemic in the Chilean healthcare system. Critical incidents are a feasible resource to identify threats to psychological safety globally and also in Chile. This is the first report in our country and even in Latin America, where internships are an important part of the curriculum and a transition to real-world practice, that deserves to be considered integrally to understand its effect and influences. Declarations Ethics approval and consent to participate The research project was approved by the Institutional Research Ethics Committee of the University (Approved in June 2021). Every participant was part of an informed consent process. Consent for publication “Not applicable” Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests Funding The authors declare that the project has the support of Universidad del Desarrollo, through the Innovation founding, from Centro de Innovación Docente 2021. 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Can Med Educ J. 2023;14(1):4-12. Published 2023 Mar 21. doi:10.36834/cmej.75591 Barnabe C, Osei-Tutu K, Maniate JM, et al. Equity, diversity, inclusion, and social justice in CanMEDS 2025. Can Med Educ J. 2023;14(1):27-32. Published 2023 Mar 21. doi:10.36834/cmej.75845 Osei-Tutu K, Duchesne N, Barnabe C, et al. Anti-racism in CanMEDS 2025. Can Med Educ J. 2023;14(1):33-40. Published 2023 Mar 21. doi:10.36834/cmej.75844 Waters HM, Oswald A, Constantin E, Thoma B, Dagnone JD. Physician Humanism in CanMEDS 2025. Can Med Educ J. 2023;14(1):13-17. Published 2023 Mar 21. doi:10.36834/cmej.75536 Green S, Labine N, Luo OD, et al. Planetary Health in CanMEDS 2025. Can Med Educ J. 2023;14(1):46-49. Published 2023 Mar 21. doi:10.36834/cmej.75438 Cupido N, Fowler N, Sonnenberg LK, et al. Adaptive Expertise in CanMEDS 2025. Can Med Educ J. 2023;14(1):18-21. Published 2023 Mar 21. doi:10.36834/cmej.75445 Thoma B, Paprica PA, Kaul P, Cheung WJ, Hall AK, Affleck E. Data-Informed Medicine in CanMEDS 2025. Can Med Educ J. 2023;14(1):54-57. Published 2023 Mar 21. doi:10.36834/cmej.75440 Young M, Szulewski A, Anderson R, Gomez-Garibello C, Thoma B, Monteiro S. Clinical Reasoning in CanMEDS 2025. Can Med Educ J. 2023;14(1):58-62. Published 2023 Mar 21. doi:10.36834/cmej.75843 Frenk J, Chen LC, Chandran L, et al. Challenges and opportunities for educating health professionals after the COVID-19 pandemic. Lancet. 2022;400(10362):1539-1556. doi:10.1016/S0140-6736(22)02092-X Braun V, Clarke V. Thematic analysis. In: Cooper H ed. APA Handbook of Research Methods in Psychology. American Psychological Association: Washington; 2012. vol. 2, pp.57–71. Román Collazo CA, Ortiz Rodríguez F, Hernández Rodríguez Y. El estrés académico en estudiantes latinoamericanos de la carrera de Medicina. RIEOEI [Internet]. 25 de julio de 2008 [citado 14 de abril de 2024];46(7):1-8. Disponible en: https://rieoei.org/RIE/article/view/1911 Triviño X, Sirhan M, Moore P, Montero L. Impacto de un programa de formación en docencia en una escuela de medicina [Impact of a diploma on medical education in a medical school in Chile]. Rev Med Chil. 2011;139(11):1508-1515. Troncoso G D, Pérez V C, Vaccarezza G G, Aguilar A C, Muñoz N N. ¿Se relaciona la capacitación docente con las prácticas pedagógicas en académicos de carreras de la salud de Chile? [The influence of pedagogic and discipline training on the teaching quality of university professors]. Rev Med Chil. 2017;145(5):610-618. doi:10.4067/S0034-98872017000500008 Al-Hussain SM, Al-Haidari MS, Kouri NA, El-Migdadi F, Al-Safar RS, Mohammad MA. Prevalence of mistreatment and justice of grading system in five health related faculties in Jordan University of Science and Technology. Med Teach. 2008;30(3):e82-e86. doi:10.1080/01421590801938845 Mavis B, Sousa A, Lipscomb W, Rappley MD. Learning about medical student mistreatment from responses to the medical school graduation questionnaire. Acad Med. 2014;89(5):705-711. doi:10.1097/ACM.0000000000000199 Pérez-Villalobos C, Ventura-Ventura J, Spormann-Romeri C, et al. Satisfaction with remote teaching during the first semester of the COVID-19 crisis: Psychometric properties of a scale for health students. PLoS One. 2021;16(4):e0250739. Published 2021 Apr 28. doi:10.1371/journal.pone.0250739 Ersan N, Dölekoğlu S, Fişekçioğlu E, İlgüy M, Oktay İ. Perceived sources and levels of stress, general self-efficacy and coping strategies in preclinical dental students. Psychol Health Med. 2018;23(5):567-577. doi:10.1080/13548506.2017.1384844 Amor Eva M, Baños Josep E, Sentí Mariano. Prevalencia del síndrome de burnout entre los estudiantes de medicina y su relación con variables demográficas, personales y académicas. FEM (Ed. impresa) [Internet]. 2020 [citado 2024 Abr 14] ; 23( 1 ): 25-33. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S2014-98322020000100005&lng=es. Epub 09-Mar-2020. https://dx.doi.org/10.33588/fem.231.1036. Gómez H P, Pérez V C, Parra P P, et al. Relación entre el bienestar y el rendimiento académico en alumnos de primer año de medicina [Academic achievement, engagement and burnout among first year medical students]. Rev Med Chil. 2015;143(7):930-937. doi:10.4067/S0034-98872015000700015 Lemos M, Henao-Pérez M, López-Medina DC. Estrés y salud mental en estudiantes de Medicina: Relación con afrontamiento y actividades extracurriculares. Archivos de medicina. 2018; 14(2), 3. Available under creative commons license in https://www.archivosdemedicina.com/medicina-de-familia/estreacutes-y-salud-mental-en-estudiantes-de-medicina-relacioacuten-con-afrontamiento-y-actividades-extracurriculares.pdf Oro P, Esquerda M, Viñas J, Yuguero O, Pifarre J. Síntomas psicopatológicos, estrés y burnout en estudiantes de medicina. Educ med. 2019; 20, 42-48. https://doi.org/10.1016/j.edumed.2017.09.003 Bastías-Vega Nancy, Pérez-Villalobos Cristhian, Alvarado-Figueroa Débora, Schilling-Norman Mary-Jane, Espinoza-Riffo Maritza, Parra-Ponce Paula et al . Maltrato en el pregrado de la carrera de Medicina: percepción de los estudiantes. Rev. méd. Chile [Internet]. 2021 Abr [citado 2024 Abr 14] ; 149( 4 ): 617-625. Disponible en: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872021000400617&lng=es. http://dx.doi.org/10.4067/s0034-98872021000400617. Maini A, Saravanan Y, Singh TA, Fyfe M. Coaching skills for medical education in a VUCA world. Med Teach. 2020;42(11):1308-1309. doi:10.1080/0142159X.2020.1788713 Ohta R, Sano C. Case Report-Driven Medical Education in Rural Family Medicine Education: A Thematic Analysis. Healthcare (Basel). 2023;11(16):2270. Published 2023 Aug 11. doi:10.3390/healthcare11162270 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4266187","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":291528400,"identity":"1a40f459-7e78-4f14-bc0d-98b3d88f4bcd","order_by":0,"name":"Soledad Armijo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYFAC5gYGHgZmMPOABIMNkGJsPIBfCyOKljSwCPFagOAwRC8+DfLtjY0P3tRYM/DPPp14wKLivN3a9sNAW2psonFpMThzsNlwzrF0BolzuRsOSJy5nbztTCJQy7G03AZcWiQS26R52IDuOcO74YBk2+1kswNALYwNh3FqkZ+R2P6b599hBnmIlnPJZucf4tfCcCOxjZm37TDQhWAtB+zMbhCwBeQXybl96TyGIC0SZ5ITzG4AbUnA4xf59uaDH958s5aTO8O7+bNEhZ292fn0hw8+1NjgdhgU8IAIZgkGhkSwygQCyuGA8QMDgz2xikfBKBgFo2DkAAA8EGcYACqMXQAAAABJRU5ErkJggg==","orcid":"","institution":"Universidad del Desarrollo","correspondingAuthor":true,"prefix":"","firstName":"Soledad","middleName":"","lastName":"Armijo","suffix":""},{"id":291528401,"identity":"451010d8-4c8a-41f5-ae2f-da97dae89569","order_by":1,"name":"Marcela Castillo Franzoy","email":"","orcid":"","institution":"Universidad del Desarrollo","correspondingAuthor":false,"prefix":"","firstName":"Marcela","middleName":"Castillo","lastName":"Franzoy","suffix":""},{"id":291528402,"identity":"d69d4d05-c412-4fb8-8514-c29879c741af","order_by":2,"name":"Valentina Fuentes Lombardo","email":"","orcid":"","institution":"Universidad del Desarrollo","correspondingAuthor":false,"prefix":"","firstName":"Valentina","middleName":"Fuentes","lastName":"Lombardo","suffix":""},{"id":291528403,"identity":"ebfc4d99-a671-4608-8239-c18f9282489d","order_by":3,"name":"Francisca Parra Agurto","email":"","orcid":"","institution":"Universidad del Desarrollo","correspondingAuthor":false,"prefix":"","firstName":"Francisca","middleName":"Parra","lastName":"Agurto","suffix":""}],"badges":[],"createdAt":"2024-04-14 19:59:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4266187/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4266187/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55062894,"identity":"b18b76cd-612c-4d0a-b59b-0b3fd75565c9","added_by":"auto","created_at":"2024-04-22 03:02:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":305552,"visible":true,"origin":"","legend":"\u003cp\u003eThemes and subthemes related to critical incidents during medicine internships in pandemic in Chile.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4266187/v1/c45eac1eeba421a391e2308c.png"},{"id":55063489,"identity":"db4e488e-ce11-4575-83c9-bbf446f151d5","added_by":"auto","created_at":"2024-04-22 03:10:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":529127,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4266187/v1/18e2539b-940f-41cf-942d-be4dcb349bc5.pdf"},{"id":55062893,"identity":"65bf05ec-8d20-4a20-91b4-614aa4ab0505","added_by":"auto","created_at":"2024-04-22 03:02:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15570,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialCriticalIncidentsMedicineInterns.docx","url":"https://assets-eu.researchsquare.com/files/rs-4266187/v1/e442893638c33778ed73c6ff.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Critical incidents experienced by medicine interns in pandemics: A qualitative study at a South American medical school","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCritical Incidents (CI) analysis in medical education began as an alternative to teaching evaluation surveys. It made it possible to identify factors associated with good teaching aimed at medical students, teachers' interpersonal behavior, planning, preparation, and the ability to lead the session well.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e Another approach was using the CI to reflect and evaluate the patient's story\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e from the perspective of preclinical cycle students, interns, residents, and practicing physicians, identifying that the concept of CI was associated with different areas or categories throughout the training process and in the professional practice. Also, the CI technique was used to define specific aspects of the curriculum, such as professionalism,\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e or to explore errors in internship practices.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn recent years, the report and analysis of CI have been used to address the inclusion of minorities,\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e stress,\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and negative experiences in students,\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e the teaching of professionalism,\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e and interprofessional training.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e Likewise, using teaching guides based on CI analysis has been proposed to contain microaggressions in the context of teaching in clinical settings.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLikewise, factors dependent on the health system emerge that generate disparity or inequities and are linked to the analysis of CIs from the health systems perspective.\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCritical health incidents are usually caused by multiple overlapping failures rather than single or individual failures. Their analysis is part of the continuous improvement process and clinical risk reduction. One of the barriers to the success of this strategy for confronting and analyzing CIs in the United States is the need for more commitment from doctors.\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e The teaching of CI analysis needs to be more emphasized at the undergraduate level. Incorporating the report of these incidents from students can improve the psychological safety of clinical practices and generate qualitative improvements in their programs.\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCI interviews exploring the challenges of caring for patients at the end of life in junior doctors and interns in Ireland show a lack of knowledge, preparedness, and support associated with a feeling of failure.\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e CI about night-time experience in medicine and pediatric interns shows that the shifts provide rich experiential learning and that interns require support to optimize workplace learning.\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e CI observation scales have been used in simulations by interdisciplinary health teams to address patient safety elements.\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOn the other hand, in the initial analysis of the pandemic scenario, some authors identified the institutional responsibility of students since they are not essential health team workers \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. It was necessary to adapt clinical teaching to the needs of students in the context of a pandemic, recommending the retirement of the students from clinical practice in this complex scenario.\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e Recently CANMED experts have analyzed the effect of the Covid-19 pandemic on virtual healthcare,\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e the relevance of humanism in the profession\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e the role of the healthcare industry in the climate crisis and its effect on patients,\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e the effect of technological innovations on adaptive learning\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e and the effects of cognitive load on clinical decision making.\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e For the Lancet Commission, the current moment offers opportunities and challenges for competency training, interprofessional education, and the use of technology. They analyze the reality of clinical practices and propose a model of foundational, specialized, and integrative competencies for health careers.\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe educative meaning of CI has been used to make the student's voice visible in different contexts but has yet to be explored to analyze this voice in a global clinical crisis. In the context of the pandemic, the variables related to clinical teaching, including internships, have undergone great changes. That fact may influence the appearance of CI linked to health care that traditional training has not considered. In that sense, there is a gap in the literature related to how the context in which the training of internships occurs during pandemics may have impacted student learning in their final years of vocational training in South America.\u003c/p\u003e \u003cp\u003eThis study aims to determine the elements that students consider as part of their CI reports in the context of internship practice during a pandemic in the years 2020\u0026ndash;2021 in Chile and identify the adaptation and support they had during this time.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eQualitative approach\u003c/strong\u003e \u003cp\u003eWe conducted a reflexive thematic analysis of participants\u0026rsquo; critical incidents. Reflexive thematic analysis is an easily accessible and theoretically flexible interpretative approach to qualitative data analysis that facilitates the identification and reflexive analysis of patterns or themes in a given data set \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eParticipants\u003c/strong\u003e \u003cp\u003eThe study was conducted on students who began Internships in 2020 and wrote their portfolios in the second semester of 2021 (July-December). The universe of interns invited to participate was 67. The final sample was defined by the reach of data saturation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eContext\u003c/strong\u003e \u003cp\u003eThe study was conducted over 6 months at the Medicine School of Universidad del Desarrollo in Santiago, Chile, a private not-for-profit graduate entry medical school. The preclinical curriculum has five years and includes clinical and simulated practices that provide students with clinical skills and interactions with real patients, standardized patients, simulated patients, and high-fidelity simulations. and provides an academic license. After that, the students begin a two-year internship period, focused on in-hospital and ambulatory care services, where they perform a supervised clinical practice, structured in clinical rotations at public facilities. During the first semester of 2020, these clerkships were modified focusing on the training in adult in-hospital practices, with fewer opportunities for practice in ambulatory care, and the inclusion of Telemedicine practices and research and simulation activities to complement the training and contextualize it to the pandemic context. The assessment system was also modified, adding a portfolio, that includes a CI report. In this CI section of the portfolio, the interns were invited to share a short narrative of a challenging, significant, or disturbing singular event from their practice to reflect on what happened and what adaptations and support they had related to the event, allowing freedom of expression.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSampling strategy, data collection, and analysis\u003c/h2\u003e \u003cp\u003e Through an informed consent process, the research project participants agreed to have their portfolios analyzed by a research team that did not participate in assessing their internships. The principal researcher (SA) anonymized the CIs extracted from the portfolios before analyzing them.\u003c/p\u003e \u003cp\u003eBefore conducting the focus groups, the volunteers participated in consent processes guided by the principal researcher (SA). An audio recording of the focus group sessions was left. The focus group consent included authorization for using the audio recordings for the analysis associated with the research.\u003c/p\u003e \u003cp\u003eFor data analysis, a six-step approach was performed by two researchers (SA, MC). In the first step of data familiarization, the research team read the CIs to identify appropriate information that may be relevant to the research question. In the second step, a codification process was performed, using a predefined codebook based on the literature in an attempt to enhance coding reliability. Given the number of participants, two researchers analyzed the texts independently (MC and SA) manually. The focus group analysis contemplated transcription of the sessions and the same codification process described for the written documents. The coding process was iterative, with three subsequent data revisions. It produced succinct descriptive labels for information relevant to the research question. In a third step, the coded data were reviewed and analyzed to understand how they were combined in terms of shared meanings, and how they formed themes and subthemes. The fourth step was the final revision of the themes, which was named in the fifth step. The sixth step, producing the report, includes the participation of two students (VF and FP) to enrich the interpretation with their perspectives.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical considerations\u003c/strong\u003e \u003cp\u003e The research project was approved by the Institutional Research Ethics Committee of the University (Approved in June 2021). Every participant was part of an informed consent process.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA voluntary sample of 24 interns agreed to have their portfolios analyzed. Thirteen participated in the focus groups. Six CI texts were coded using the pre-established codebook, finding that 90% of the initial codings matched the predefined categorization system. Two new codes emerged related to the ethical dimension of clinical teaching and the crisis adaptations students establish with their means. The codings of the two researchers using the codebook were 95% agreeable.\u003c/p\u003e \u003cp\u003eThe coding process identified 22 definitive codes that were synthesized into nine subthemes and three themes that described types of CIs, factors that influence them, and effects generated by CI (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes, subthemes and definitive codes related to critical indicents during medicine internships in pandemic in Chile.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefinitive code\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eCauses of CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNegative interpersonal relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResidents\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical teachers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eThe healthcare context (non-COVID)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplexity of clinical cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWork overload\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe COVID context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients and family communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eFactors that influence CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePersonal factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eManagement of emotions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTolerance to uncertainty and frustration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-technical skills\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTeaching process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTeachers overloaded with clinical work\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe internship experience\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePedagogical potential of CI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTypical clinical cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunication styles\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eEffects generated by CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEmotions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative is the first response\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositive about their contribution\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLearning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-reflection after CI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbout healthcare system\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTeamwork\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAdaptations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchool preparation (simulations)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTeachers support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthcare personnel support and teamwork\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBelow, we describe the codes, subthemes and themes, the reflexive interpretation of their relations (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and provide representative student quotes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003e1.- Causes of CIs\u003c/h3\u003e\n\u003cp\u003eThe participants considered that the COVID-19 context influenced their critical event to a greater or lesser extent, independent of the specific characteristics of the incident reported.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"What happened to me was not because of the pandemic, but I think it still adds to the pandemic in all cases\" Intern3\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\"My CI did not have much to do with the pandemic, but it took place in a health system collapsed by the pandemic, so you could say that it was related to the pandemic, I do not know if you understand. Intern7\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIt was possible to categorize three areas or groups of CIs.\u003c/p\u003e \u003cp\u003eThe most predominant were those related to bad experiences of interpersonal relationships with other health professionals or teachers, and \"questionable\" or \"unacceptable\" behavior on the tutors' actions.\u003c/p\u003e \u003cp\u003eAnother group was concerned with the health context, which operates as a backdrop. The health situation permanently and transversally colors the most critical events. The cases related to the CI were of high biopsychosocial complexity, in which the ethical dimension associated with difficult decisions emerges.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"They were more experiential things of the practice concerning the moment the country and the hospital were going through, with the burden that existed and how patients were being handled in general, such as people dying in the corridor or young people dying, situations that were anomalous to the classic medicine we knew. That might be perhaps a little bit more prevalent than the rest, but at that time, there were all kinds of incidents, emotional, family, work, uncertainty in the hospital, there was everything\". Intern14\u003c/em\u003e \u003c/p\u003e \u003cp\u003eManaging Covid patients and their families is part of some of the CI. In these situations, a high emotional burden is evident, and the assignment of responsibilities forces them to learn quickly and strengthen their autonomy.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Many times, I was the one who had to give information to patients and families who were going to die, so managing families was complex, but it taught me many things. Sometimes they were right and then they were wrong, it was crazy...\". Intern20\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003e2.- Personal factors influencing CI\u003c/h3\u003e\n\u003cp\u003eThe interns state that the personal factors are related to the high emotional demand the pandemic placed on everyone. The vulnerability and sensitivity that prevailed at the worst moment of the crisis influenced critical events related to interpersonal issues and communication with postgraduate residents, teachers, and other health professionals. The experience varies according to the timing of the reported CI. The high demands of care work meant that all those involved found their non-technical skills thresholds altered: empathy, frustration tolerance, and teamwork skills, to name a few. These skills played a key role and needed to be moderated and worked on.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Mine was related to a specific patient, but also how that critical event triggered a response from the health care team and how that ultimately impacted my values\". Intern3\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn another sense, the high level of uncertainty of the academic times influences, given that the planning of the internships was being constructed according to the evolution of the pandemic in the country. For those interns who were more structured, not knowing precisely what course their training process would take generated uncertainty that was difficult to manage and impacted performance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I like to have a bit of structure and to know what comes next and to arrive at the internship was to arrive at that part of the career in which you become a doctor, and with the internship one was going to be ready for life and one knew that you started with the electives, and then pediatrics (...) and with my more square mind it was very difficult for me to get on the bandwagon that everything was going to be on the fly\". Intern1\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.- Factors in the teaching process\u003c/h2\u003e \u003cp\u003eThe teaching role was somewhat absent during the health crisis since the clinical duties of doctors and health personnel played a critical role and occupied their time and energy. This is understood and justified from the point of view of urgency, even though, in the end, it still affects the learning experience of the interns.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"As my incident was at the end of the first wave and everything was stabilizing a bit in the hospital, in my experience, there were teachers, but depending on the rotation within the internship, as one is not always in the same team within the internship, one rotates between teams and in some there is a lot of teaching, they monitor you much more, but in others you are more left out...\". Intern8\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe interns felt that the approach to the CI changed depending on whether it was experienced at the beginning, during the process, or later in the health crisis. The more advanced the crisis, the more coping tools they feel they have acquired to deal with the difficulties of a new critical event. The interviewees share that the critical event provides much learning, the experiences serve as an example for future situations, and their reporting enriches that learning.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The CI was at the very beginning of the whole period where I wrote the portfolio, so I had to remember the critical incident many times, and it often served me as an example (...) if it happened to me now, maybe I would have more tools to be able to face something like this\". Intern1\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.- Health System Incidence\u003c/h2\u003e \u003cp\u003eSome interviewees refer to the health context, independent of the health crisis. They report incidents that seem familiar to \"the life of doctors,\" responding to a style of communication and negative confrontation that would be typical of the sector and independent of the contingency.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I think that if it happened now, when the pandemic is calmer, it would still have been a CI, because it has more to do with how things are done in health, and with some styles that are very specific to the field and how things work\". Intern8\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e5.- Effects generated by CIs\u003c/h2\u003e \u003cp\u003eStudents express negative emotions such as pain, sadness, grief, or crying, which occur as an immediate reaction to critical events of a clinical or biological nature. Likewise, they express indignation, anger, and frustration when the critical event is linked to situations of coexistence and dealing with the health team and teachers. When the emotions were related to reflection after the critical event, in which the students themselves had managed to adapt, the most frequently described states were motivation, pride, and joy.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"This was different, a sepulchral silence and then came the second moment of pain that marked me the most, handing the father his dead baby\" (Intern24).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome interns declare to be able to carry out a reflexive activity that generates learning after a CI. They highlight the involvement of their family and adaptation as the predominant feeling. These adaptations were dependent on the student and their close social environment\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"This made me reflect on the fragility of life, and how it can surprise us negatively when we least expect it\" (Intern19).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome interns mentioned that the school provides curricular opportunities to prepare for that crisis. Anticipation with simulations of difficult communication was the most important resource they mentioned. They also consider that connection with some teachers was a positive factor in facing the crisis\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I was very grateful to the doctor because if it had not been for her, I would not have been able to understand the reason for the patient's behavior...\" (FGXII7\u0026thinsp;=\u0026thinsp;connection with teacher).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn a few cases, the CI provides the opportunity to learn more about the Chilean health system, including clinical protocols or organization of the country.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I learned more about SENAME and the different options that exist in our country, having to evaluate in a \"balance\" way in which environment the patient would benefit the most\". (FGXIV 15\u0026thinsp;=\u0026thinsp;country organization)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe positive elements described concerning the health system were related to the actions and attributes of the personnel and the health team's teamwork.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I spoke to the doctor in charge of the floor, and we managed to get him in to say goodbye\" (FGXXIV 23\u0026thinsp;=\u0026thinsp;Flexibility).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe principal findings in this study were that the CIs were predominantly related to clinical cases of non-COVID pathologies that occurred in a public hospital and caused negative emotions. This is similar to the findings of another study that describes CIs related to negative experiences in students before pandemics\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e and highlights that the conditions of clinical teaching during internships are complex and independent of the actual crisis. This is an important issue because determines that medical schools should be aware of the existence of moral distress and challenges to psychological safety in clinical settings in our country.\u003c/p\u003e \u003cp\u003eWhen observing the emotional impact described by the students, the role of the family and friends' support they received directly or indirectly stands out, which was considered superior to that received in learning in a normal health situation. This support was superior to that of their peers, clinical tutors, school, or clinical service. This reflects the fact that the majority prefers to vent and take refuge in people outside the internship, as was stated in previous studies in the Latin American context.\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePreviously, CI has been used to address positively the teaching of professionalism, identifying “\u003cem\u003ealtruism, accountability, duty, excellence, honor and integrity, and respect for others”\u003c/em\u003e as part of the conduct of teachers as role models\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. That situation is also present in some CI analyzed in this study when the teachers support the students or reflect on the CI. However, in other cases, the interns describe \"questionable\" or \"unacceptable\" behavior on the tutors' actions, reflecting the dualism of teachers' role modeling. It has been suggested that teacher training of medical professionals would help to contain this negative role model. However, studies on the training of clinicians in universities in Chile are scarce\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e and do not refer to the transfer to practice of the concepts or values transmitted in the training programs. Likewise, using teaching guides based on CI analysis has been proposed to contain microaggressions in the context of teaching in clinical settings\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. For us, CI is a useful tool to continue analyzing these complex dimensions of teaching and also a tool to reflect on how to address the difficulties in teaching and learning when role modeling is not precisely ideal.\u003c/p\u003e \u003cp\u003eThe high demands of care work related to the crisis were an explanation the interns accepted from their teachers. CI analysis has been used to understand the stress in medicine students\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. In healthcare education, the studies highlight the excessive exigencies during the formation\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e, exigencies that sometimes surpass the student in terms of the resources available to him/her, the learning opportunities he/she has had, and the level of education he/she is pursuing.\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e The workload is one of the factors most associated with stress in this group\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e, and it is only one of the mental health problems they face. Burnout, anxiety, depression, alcohol dependence, and suicidal ideation, are other important problems that affect the students.\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e This is complex, given that medical students should learn how to protect the health of others, and for that, it is necessary that they learn to protect their own in formative contexts\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e, and that the formative contexts allow it. A recent study in Chile concludes that mistreatment is present in a medical school \u003csup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e, showing that the role models of clinical tutors do not always guarantee the psychological safety of interns and that this is a problem in Chile.\u003c/p\u003e \u003cp\u003e The interns understood the sense of urgency that the Covid-19 emergency established and valued that their teachers should work on their care activities over teaching activities. In this sense, the high level of uncertainty of the academic times was difficult to manage and could impact performance. The vulnerability and sensitivity that prevailed at the worst moment of the crisis influenced critical events. According to Maini, \u003cem\u003e“Healthcare professionals and students globally are experiencing an increasingly 'VUCA' (volatile, uncertain, complex and ambiguous) healthcare and educational climate”\u003c/em\u003e\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e, and coaching activities are important during their formation in order to allow them to face this complexity and provide better care to their patients, that also experience this complexity. Another strategy proposed to address this VUCA context is Case-Based Education (CBE), which helps the students better understand the patient and families' perspective in this global context.\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eReflecting on the critical instances allows students to imagine how to take the learning to future practice. In conclusion, thanks to the analysis developed in this study, the main adaptations that students reported in a reflective and descriptive portfolio in the midst of a pandemic were: the exercise of greater autonomy, the assessment of greater academic flexibility received from medical school as manager of the process and that in a possible future health care crisis, the main hospital for professional practices cannot guarantee organic support for teaching and that a strategy for this to improve would be to have a greater teaching presence or a link preference of students with the best models of professionalism.\u003c/p\u003e \u003cp\u003eThe role of teachers in the pandemic has been transformed. Tutor and apprentice worked together for a global challenge, they were complicit and together they overcame the natural fear of the unknown. The portfolio seems to show that it is a good way to open up the expression of those emotions with great confidence and achieve new meaning in learning. The interns could understand and measure how the health context influenced their experiences. At the same time, they identify the reflective process of creating a CI as a good way of working on learning from a limiting life experience and not forgetting what it was like to do the internship during the Covid-19 pandemic.\u003c/p\u003e \u003cp\u003eA fundamental component of life-long education is empowering students to uphold their purpose and mental well-being. This entails acquiring the skills to harmonize their professional endeavors with non-work-related aspects and cultivating coping mechanisms to manage stress and surmount challenges effectively.\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e This holds particular significance in their aptitude to adapt to the student's critical events they experienced. As previously indicated, most students sought support from their familial and social circles beyond the confines of medical school, implying the presence of robust networks that aided them in facing adversity and addressing negative emotions. This leads to the presumption that some individuals might have succumbed to the burdens of stress and burnout without a sturdy support system beyond the realm of medical school or clinical service. Consequently, this underscores the imperative role that medical schools and clinical mentors should play as support systems and student confidants. In depicting critical events a few students accentuated the pivotal significance of clinical mentors in their adaptation process, which sheds light on their limited involvement in this specific facet of life-long education. This leads us again to mention the importance of coaching by faculties and clinical mentors in an increasingly VUCA clinical environment, where no one other than the peers and professionals involved can support and help solve current problems faced by health professionals.\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOne of the strengths of the study is that includes students' perspectives on the data and interpretation, validating the role of formative research initiatives during the curriculum. One of the weaknesses is that the main analysis of the qualitative data was performed by one single researcher, who has research experience but also has some biases that\u003c/p\u003e \u003cp\u003eThe elements related to the hospital organization, its protocols and processes, and the dynamics of teamwork in the hospital appear in a smaller proportion. It seems that the vision of the interns about CI is far from the healthcare concept, and that is not visible to them that there is a need to analyze this CI from an organizational perspective in order to improve the healthcare process and reduce clinical risk. In that sense, these findings support the idea that physicians can be a barrier to implementing continuous improvement programs.\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe health system also changed the teaching process after the pandemic. This idea does not emerge in the CI analysis. In the literature, there are some descriptions of how the changes in health systems define new aspects to consider in the teaching process, such as humanism in the profession\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e or the effects of cognitive load on clinical decision-making \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Further research could examine these elements from the interns' perspectives in our country.\u003c/p\u003e \u003cp\u003eSome unanswered questions are related to the educational effect on patient safety of CI analysis, which has not yet been analyzed or reported worldwide. The recognition of the security elements linked to the analysis of critical health incidents, from the perspective of medical students, can provide useful guidelines to include these concepts and elements in the curriculum of other professionals of the health team who exercise leadership roles or in the training of other professions as lawyers or engineers who are linked to legal processes, administration or health planning.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eCI analysis allows interns to reflect and imagine how to bring learnings into their future practice. The primary emotions associated with CI were negative, and their adaptations were autonomous. The school could improve with more teacher support and better role models to manage CI and support the interns' mental health better. One important topic to address is if the teachers are really available and prepared to be supportive, or if they are part of the causes of the CI.\u003c/p\u003e\u003cp\u003eThis article is important because it includes an actual perspective of medicine interns' experiences during internships. The interns reflect on some conditions that transcend the pandemic in the Chilean healthcare system. Critical incidents are a feasible resource to identify threats to psychological safety globally and also in Chile. This is the first report in our country and even in Latin America, where internships are an important part of the curriculum and a transition to real-world practice, that deserves to be considered integrally to understand its effect and influences.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research project was approved by the Institutional Research Ethics Committee of the University (Approved in June 2021). Every participant was part of an informed consent process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not applicable\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the project has the support of Universidad del Desarrollo, through the Innovation founding, from Centro de Innovaci\u0026oacute;n Docente 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge Sandra Ferrada and Marcela Asseff fot their support in the early phase of this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMetcalfe, D. 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Disponible en: http://www.scielo.cl/scielo.php?script=sci_arttext\u0026amp;pid=S0034-98872021000400617\u0026amp;lng=es. http://dx.doi.org/10.4067/s0034-98872021000400617.\u003c/li\u003e\n\u003cli\u003eMaini A, Saravanan Y, Singh TA, Fyfe M. Coaching skills for medical education in a VUCA world. Med Teach. 2020;42(11):1308-1309. doi:10.1080/0142159X.2020.1788713\u003c/li\u003e\n\u003cli\u003eOhta R, Sano C. Case Report-Driven Medical Education in Rural Family Medicine Education: A Thematic Analysis. Healthcare (Basel). 2023;11(16):2270. Published 2023 Aug 11. doi:10.3390/healthcare11162270\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical Student, Critical Incident Technic, COVID-19, Mental Health, Psychological Safety","lastPublishedDoi":"10.21203/rs.3.rs-4266187/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4266187/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCritical Incidents (CI) during clinical practice can provide relevant information regarding students' stress, weaknesses in the teaching process, psychological safety, and the healthcare system. This study aimed to determine the elements considered by students to be CI during the COVID-19 pandemic in Chile.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study was conducted on a sample of voluntary medical interns. Data production techniques were documentary analysis of the CI described in portfolios and two focus groups. Two researchers performed a reflexive thematic analysis of the CI and the focus groups. The Institutional Ethics Committee approved the research protocol.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-four interns voluntarily participated. The coding process identified 22 definitive codes that were synthesized into nine subthemes and three themes that described types of CIs, factors that influence them, and effects generated by CI. The main findings were that CI were mainly related to non-Covid pathologies, causing negative emotions. They were cases of high biopsychosocial complexity, in which the ethical dimension of difficult decisions or \"questionable\" or \"unacceptable\" behaviors emerges. Some CI were linked to the human relationship between students and teachers or between the health team, or communication with patients and their families. Elements related to hospital organization were less described. The adaptations, learning, and reflections referred to the intern's professional role, ethics, communication skills, and self-care; and were produced autonomously, with little teaching support.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eCI analysis allows interns to reflect and imagine how to bring learnings into their future practice. The primary emotions associated with CI were negative, and their adaptations were autonomous. The school could improve with more teacher support and better role models to manage CI and support the interns' mental health better. One important topic to address is if the teachers are really available and prepared to be supportive, or if they are part of the causes of the CI.\u003c/p\u003e","manuscriptTitle":"Critical incidents experienced by medicine interns in pandemics: A qualitative study at a South American medical school","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-22 03:01:56","doi":"10.21203/rs.3.rs-4266187/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-04T11:11:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-22T10:43:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109454169597657418639004822291926339508","date":"2024-09-10T13:59:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-06T02:03:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320077974304821632990862431584075032557","date":"2024-07-22T07:57:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73942189941153483364861009578123931779","date":"2024-07-22T01:01:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150099888677328302581126173909642786742","date":"2024-07-20T19:55:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265226689313484035938455241446059314472","date":"2024-07-20T13:23:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99805873654896059083081006676822544142","date":"2024-07-18T12:49:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-01T09:57:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-01T09:48:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-15T17:54:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-15T11:18:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-04-14T19:55:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a1fbec3-3ede-406b-9ea3-0fea8a53e809","owner":[],"postedDate":"April 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T08:10:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-22 03:01:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4266187","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4266187","identity":"rs-4266187","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}