Attending rounds: What do the all-star teachers do?

Aim: To examine differences in the types of teaching activities performed during rounds between the most effective and least effective inpatient teaching attendings.

Methods: Participants included 56 attending physicians supervising 279 trainees. Trained observers accompanied teams during rounds and recorded the frequencies of educational activities that occurred. Students and residents then rated their satisfaction with the teaching on rounds.

Results: Attending physicians with the highest learner satisfaction scores performed significantly more teaching activities per patient than attending physicians who were rated as average or less-effective (2.1 vs. 1.4 vs. 1.5; p?=?.03). There were significant differences in the frequencies of 3 out of the 9 specific teaching activities observed, including answering specific patient-care related questions (77% vs. 66% vs. 47%; p?=?.003), teaching on learner chosen topics (8% vs. 2% vs. 2%; p?=?.02), and providing feedback (31% vs. 10% vs. 0.1%; p?=?.001).

Conclusions: Specific categories of teaching activities—patient-specific teaching, teaching on learner-identified topics, and providing real-time feedback—are performed more frequently by the highest-rated attending physicians, which can guide faculty development.     

The association between Situational Judgement Test (SJT) scores and professionalism concerns in undergraduate medical education

Abstract

Introduction: Situational judgement tests (SJTs) are widely used in selecting medical students and doctors. Emerging evidence suggests SJTs are capable of testing an individual’s ability to respond to role-relevant professionalism scenarios, however, evidence is lacking for their use in identifying students with concerning professional behaviours.

This study aimed to determine the association between medical student professionalism-based SJT scores and recorded professionalism concerns during training.

Methods: A cross-sectional study was conducted utilising SJT scores from second-year medical students and occurrences of student professionalism concerns. Concerns were reviewed and mapped to General Medical Council standards. Multivariate logistic regression was used to determine associations between SJT scores and professionalism concerns.

Results: 247 students were included in the study. For every point increase in SJT score, students were 10% less likely to have multiple professionalism concerns [OR (95% CI) 0.90 (0.83–0.97); p?=?.007].

Students scoring below 1 and 2 standard deviations from the mean score were 4 and 11-times more likely to have multiple concerns [OR (95% CI) 4.52 (1.12–18.25); p?=?.034] and [OR (95% CI) 11.45 (1.72–76.15); p?=?.012].

Conclusion: Lower SJT scores were significantly associated with an increased risk of professionalism concerns. These findings support the potential for SJT exams to identify medical students that may require closer supervision and remediation during undergraduate education.     

The simulated clinical environment: Cognitive and emotional impact among undergraduates

Context: Simulated clinical immersion (SCI) is used in undergraduate healthcare programs to expose the learner to real-life situations in authentic simulated clinical environments. For novices, the environment in which the simulation occurs can be distracting and stressful, hence potentially compromising learning.

Objectives: This study aims to determine whether SCI (with environment) imposes greater extraneous cognitive load and stress on undergraduate pharmacy students than simulated patients (SP) (without environment). It also aims to explore how features of the simulated environment influence students’ perception of learning.

Methods: In this mixed-methods study, 143 undergraduate pharmacy students experienced both SCI and SP in a crossover design. After the simulations, participants rated their cognitive load and emotions. Thirty-five students met in focus groups to explore their perception of learning in simulation.

Results: Intrinsic and extraneous cognitive load and stress scores in SCI were significantly but modestly higher compared to SP. Qualitative findings reveal that the physical environment in SCI generated more stress and affected students? focus. In SP, students concentrated on clinical reasoning. SCI stimulated a focus on data collection but impeded in-depth problem solving processes.

Conclusion: The physical environment in simulation influences what and how students learn. SCI was reported as more cognitively demanding than SP. Our findings emphasize the need for the development of adapted instructional design guidelines in simulation for novices.     

The impact of simulated patient death on medical students’ stress response and learning of ACLS

Introduction: There is considerable controversy as to whether the simulator should die during high-fidelity simulation (HFS). We sought to describe the physiologic and biochemical stress response induced by simulated patient death as well as the impact on long-term retention of Advanced Cardiovascular Life Support (ACLS) knowledge and skills.

Methods: Twenty-six subjects received an American Heart Association (AHA) ACLS provider course. Following the course, subjects participated in HFS and were randomized to simulated death or survival. Heart rate and salivary cortisol (SC) and dihydroepiandrosterone (DHEA) were collected at this time. Subjects returned six months later for a follow-up simulation in which ACLS knowledge and skills were tested.

Results: For all participants, there was an increase in heart rate during simulation compared with baseline heart rate (+ 32 beats/minute), p < 0.0001. Similarly, SC and DHEA were higher compared with baseline levels (+ 0.115?μg/dL, p <0.01 and + 97?pg/mL, p < 0.001, respectively). However, the only statistically significant difference between groups was an increase in heart rate response at the end of the simulation compared with baseline in the death group (+ 29.2 beats/minute versus + 18.5 beats/minute), p < 0.05. There was no difference on long-term knowledge or skills.

Conclusions: Learners experience stress during high-fidelity simulation; however, there does not appear to be a readily detectable difference or negative response to a simulated patient death compared with simulated survival.     

Exam anxiety in the undergraduate medical students of Taibah University

Abstract

Background and objectives: Assessment is perceived to create highly stressful environment among medical students. Several studies have reported exam-related anxiety symptoms but the contributing factors seem to differ across institutions. This study aimed to determine the prevalence of exam anxiety, gender differences and the variables that moderate exam anxiety among students of a Saudi medical school.

Methods: A cross-section study was done on 5th year medical students by administering a 12-statement self-administered questionnaire. The degree of exam anxiety was gauged by a visual analog scale.

Results: Of 125 students, 111 responded (response rate 89%). About 65% students experienced exam anxiety due to various reasons. Studying all night before exam (28 students; 25.2%) and extensive course load (26 students; 23.4%) were the major confounding factors. Female students experienced more stress due to extensive course load as compared with male students (p?=?.00).

Conclusions: The data about the identified risk factors for exam anxiety can help medical educators to deeply understand the reasons for exam anxiety. There is a need to reassess the amount of study material in undergraduate medical curricula and students need to organize their time management skills to cope with exam anxiety.     

Evaluating the long-term impact of faculty development programs on MCQ item analysis

Abstract

Purpose: Evaluating the long-term impact of faculty development programs (FDPs) can help monitor the effectiveness of the program and identify areas for development. This study examined long-term differences in confidence, knowledge, behaviors, and policies of faculty members who attended FDPs on multiple choice question (MCQ) item analysis and faculty members who did not attend the FDPs.

Methods: A cross-sectional study design was used, by administering a 24-item survey to a representative sample (simple random selection) of 61 faculty members at King Abdulaziz University Faculty of Medicine.

Results: Among respondents, 34% did not attend FDPs; 53% attended 1–3 FDPs; and 13% attended more than 3 FDPs on MCQ item analysis. Results showed that faculty knowledge on elements of MCQ item analysis was significantly greater (p?=?.01) for members who attended the FDPs. Faculty who attended FDPs on MCQ item analysis were twice more likely to conduct item analysis in general (p?=?.020) and four times more likely to conduct item analysis for more than 70% of module examinations (p?=?.005).

Conclusion: FDPs focused on MCQ item analysis can yield systematic changes on faculty confidence, knowledge, and behaviors. Moreover, FDPs also need support from the department and need sustained strategic support to ensure continued effectiveness.     

The effect of stress on learning in surgical skill acquisition

Background: An excessive level of stress and anxiety in medical education can have a negative impact on learning. In particular, the interaction between attending surgeons and trainees in the operating room could induce stress on trainees that is counterproductive, especially if the teaching style or feedback is unduly harsh or critical.

Aim: To characterize the effects of stress resulting from attending–trainee interaction during surgical skill acquisition.

Methods: Forty medical students learned to perform the FLS pattern-cutting task for the first time in one of four scenarios. In the control condition, no mentor was present. In the three experimental conditions, participants were observed, encouraged, or criticized by an expert surgeon.

Results: Task performance, as well as physiological and subjective indicators of stress, were measured. Taking both speed and accuracy into account, participants who were criticized performed the worst on the task, and those who were encouraged performed best. Physiological and subjective measures indicated that the criticized participants experienced the highest level of stress and anxiety.

Conclusion: Even though providing constructive criticism to trainees is inevitable during the course of teaching, an exceedingly critical and negative mentoring style by attending physicians could be detrimental to trainees’ acquisition of surgical skills.     

Using a self-regulated learning-enhanced video feedback educational intervention to improve junior doctor prescribing

Abstract

Introduction: Medical school graduates in the UK consistently report feeling underprepared for the task of prescribing when embarking on practice. The effective application of self-regulated learning (SRL) approaches and feedback on complex tasks are associated with improved outcomes in practice-based clinical skills.

Aims: This study aimed to investigate the effectiveness of an educational intervention using SRL-enhanced video feedback for improving the prescribing competency of junior doctors.

Methods: A prospective cohort study was designed to compare intervention and control cohorts of junior doctors undertaking simulated clinical encounters at the beginning and end of their 4-month rotation through renal medicine.

Results: The improvement in prescribing competency for the intervention cohort was significant (p?<?0.001) with large effect size (d?=?1.42). Self-efficacy improved in both cohorts with large (control cohort p = 0.026, r= 0.64) and medium (intervention cohort p = 0.083, d = 0.55) effect sizes. Goal setting and self-monitoring skills improved in the intervention cohort only with medium effect size (p?=?0.096, d?=?0.53).

Conclusions: SRL-enhanced video feedback is effective for improving prescribing competency and developing SRL processes such as goal setting and self-monitoring skills in simulated clinical encounters. Further research is required to evaluate transferability to other clinical sub-speciality contexts and investigate the effectiveness of the intervention for improving prescribing in non-simulated settings.     

Use of an objective structured clinical exam (OSCE) for early identification of communication skills deficits in interns

Introduction: There is limited information about whether OSCE during GME orientation can identify trainee communication deficits before these become evident via clinical performance evaluations.

Methods: Ninety-seven interns matriculating to eight residency programs in six specialties at four hospitals participated in a nine-station communication skills OSCE. Ratings were based on the “Kalamazoo, adapted” communication skills checklist. Possible association with intern performance evaluations was assessed by repeated-measures logistic regression and ROC curves were generated.

Results: The mean OSCE score was 4.08?±?0.27 with a range of 3.3–4.6. Baseline OSCE scores were associated with subsequent communication concerns recorded by faculty, based on 1591 evaluations. A 0.1-unit decrease in the OSCE communication score was associated with an 18% higher odds of being identified with a communication concern by faculty evaluation (odds ratio 1.18, 95% CI 1.01–1.36, p?=?0.034). ROC curves did not demonstrate a “cut-off” score (AUC=?0.558). Non-faculty evaluators were 3–5 times more likely than faculty evaluators to identify communication deficits, based on 1900 evaluations.

Conclusions: Lower OSCE performance was associated with faculty communication concerns on performance evaluations; however, a “cut-off” score was not demonstrated that could identify trainees for potential early intervention. Multi-source evaluation also identified trainees with communication skills deficits.     

Incentives for recruiting trainee participants in medical education research

Introduction: In the growing field of medical education research, participant recruitment can be challenging. Incentives, either tangible or intangible, may be offered to encourage participation. This study aimed to understand these incentives and explore the relationship between study quality and incentives in medical education research.

Methods: We reviewed research studies examining medical trainees published in five major journals in 2008. Tangible and intangible incentives used in recruitment were extracted by two researchers. For each quantitative article, medical education research quality instrument (MERSQI) score was calculated and citation counts for all articles were compiled.

Results: Of 215 included articles, 8% explicitly reported incentives. Tangible incentives (value range $15–$60 USD) were offered in 7.9% of studies. Intangible incentives were identified in 30% of studies but only one specifically discussed their use. Tangible incentives correlated with a higher MERSQI score (p?p?Conclusion: Most studies in medical education did not describe incentives for participation. Information regarding incentives should be reported in all studies to help inform future recruitment efforts and also to understand the study context including factors that may influence participants motivation.     

Long-term benefits by a mind–body medicine skills course on perceived stress and empathy among medical and nursing students

Background: A significant number of medical students suffer from burnout symptoms and reduced empathy. This controlled, quasi-experimental study aimed to investigate whether a mind–body medicine (MBM) skills course could reduce perceived stress and increase empathy and self-reflection in medical and nursing students.

Methods: The MBM course (consisting of experiential sessions of mind–body techniques and group reflections) was piloted among Dutch medical students and Swedish nursing students. Main outcome variables were perceived stress (PSS), empathy (IRI subscales perspective taking, fantasy, empathic concern, and personal distress), and self-reflection (GRAS). Participating and control students completed questionnaires at baseline, post-intervention, at 6 and 12 months follow-up.

Results: Seventy-four medical and 47 nursing students participated in the course. Participating medical students showed significantly increased empathic concern [1.42 (95% CI 0.05, 2.78), p?=?0.042], increased fantasy [3.24 (95% CI 1.58, 4.90), p?p?=?0.010] compared to controls until 12 months follow-up. Participating nursing students showed significantly decreased levels of perceived stress [?5.09 (95% CI ?8.37, ?1.82), p?=?0.002] and decreased personal distress [?5.01 (95% CI ?6.97, ?3.06), p?Conclusions: This study demonstrated long-term beneficial effects of the MBM course on perceived stress and empathy in medical and nursing students.     

Comparison of faculty assessment and students’ self-assessment of performance during clinical case discussions in a pharmacotherapy capstone course

Objectives: The primary objective of this study was to compare faculty assessment and third year students' self-assessment of performance in clinical case discussions. The secondary objective was to evaluate if student characteristics influence self-assessments.

Methods: This retrospective analysis compared faculty and student self-assessment scores for two clinical case discussions using Spearman’s correlation and Wilcoxon’s signed ranks test. Chi-squared test was used to compare frequency of faculty and student self-assessments indicating the highest possible rating for the pooled score and for each individual component. The pooled score included three individual components: level of engagement, quality of contribution, and professionalism.

Results: Pooled faculty and student self-assessments correlated for both the first (r?=?0.41, p?r?=?0.35; p?p?=?0.25) and second (58.6% vs. 47.4%, p?=?0.05) clinical case discussions. Student characteristics (age, gender, and grade point average at graduation) did not influence self-assessments.

Conclusions: Students’ self-assessment correlated with faculty assessment of performance during clinical case discussions. Increased use of self-assessments for professional development in pharmacy and other healthcare professional curricula should be considered.     

The OSCE progress test – Measuring clinical skill development over residency training

Purpose: The purpose of this study was to explore the use of an objective structured clinical examination for Internal Medicine residents (IM-OSCE) as a progress test for clinical skills.

Methods: Data from eight administrations of an IM-OSCE were analyzed retrospectively. Data were scaled to a mean of 500 and standard deviation (SD) of 100. A time-based comparison, treating post-graduate year (PGY) as a repeated-measures factor, was used to determine how residents’ performance progressed over time.

Results: Residents’ total IM-OSCE scores (n?=?244) increased over training from a mean of 445 (SD?=?84) in PGY-1 to 534 (SD?=?71) in PGY-3 (p?<?0.001). In an analysis of sub-scores, including only those who participated in the IM OSCE for all three years of training (n?=?46), mean structured oral scores increased from 464 (SD?=?92) to 533 (SD?=?83) (p?<?0.001), physical examination scores increased from 464 (SD?=?82) to 520 (SD?=?75) (p?<?0.001), and procedural skills increased from 495 (SD?=?99) to 555 (SD?=?67) (p?=?0.033). There was no significant change in communication scores (p?=?0.97).

Conclusions: The IM-OSCE can be used to demonstrate progression of clinical skills throughout residency training. Although most of the clinical skills assessed improved as residents progressed through their training, communication skills did not appear to change.     

Exploring the potential uses of value-added metrics in the context of postgraduate medical education

Context: Increasing pressure is being placed on external accountability and cost efficiency in medical education and training internationally. We present an illustrative data analysis of the value-added of postgraduate medical education.

Method: We analysed historical selection (entry) and licensure (exit) examination results for trainees sitting the UK Membership of the Royal College of General Practitioners (MRCGP) licensing examination (N?=?2291). Selection data comprised: a clinical problem solving test (CPST); a situational judgement test (SJT); and a selection centre (SC). Exit data was an applied knowledge test (AKT) from MRCGP. Ordinary least squares (OLS) regression analyses were used to model differences in attainment in the AKT based on performance at selection (the value-added score). Results were aggregated to the regional level for comparisons.

Results: We discovered significant differences in the value-added score between regional training providers. Whilst three training providers confer significant value-added, one training provider was significantly lower than would be predicted based on the attainment of trainees at selection.

Conclusions: Value-added analysis in postgraduate medical education potentially offers useful information, although the methodology is complex, controversial, and has significant limitations. Developing models further could offer important insights to support continuous improvement in medical education in future.     

Training junior faculty to become clinical teachers: The value of personalized coaching

Abstract

Background: Junior clinical faculty require institutional support in the acquisition of feedback and clinical supervision skills of trainees. We tested the effectiveness of a personalized coaching versus guided self-reflection format of a faculty development program at improving faculty skills and self-efficacy.

Methods: Participants were evaluated both before and after the program using a four-station Objective Structured Teaching Exercise (OSTE). A gain-score analysis, one-way ANOVA, and paired t-tests were used to evaluate both groups. The impact on the learning environment was measured by resident ratings of the Maastricht Clinical Teaching Questionnaire.

Results: One hundred and twenty-seven participants completed the study over a three-year period. Both groups had significant improvements in self-efficacy. Participants in the coaching group demonstrated superior performance in encouraging learner self-reflection, teaching effectiveness, verifying learner understanding, exploring feelings/needs, and defining learning objectives. Over a 5-year period, the overall institutional learning climate significantly improved concerning faculty role-modeling, coaching, articulation, and explorations skills.

Conclusion: Offering a contextualized faculty-development program using OSTEs that provides multiple opportunities for feedback and is focused on creating a community of practice is an effective method to facilitate the transfer of skills to the clinical environment, supports teacher identity development, and favorably impacts the learning climate.     

Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises – Practical tips for an ‘integrative resilience’ approach

Abstract

Public health crises, including pandemics, are associated with significant health risk and concomitant stress, fear, decreased sense of control, and uncertainty. Deleterious impact on both physical and mental health can result, including for healthcare professionals and health professions trainees. Changes in governmental policies and hospital protocols for healthcare professionals as well as disruption of educational formats and requirements for trainees can ensue. Difficult anxiety-provoking realities of public health crises including pandemics which involve caring for many seriously ill patients, moral distress including difficult care decisions, personal health risk, and/or potential risk to one’s family can take a dire toll on the mental health of healthcare professionals at all stages of the professional lifecycle. Educational disruptions can create significant anxiety for trainees about completing requirements and achieving competencies. Within this, coping skills may be challenged and strengths may be elucidated as well. Such crises create an imperative for medical educators to support trainees’ wellbeing through adaptive flexibility for curriculum innovation and culturally sensitive resilience and wellbeing interventions. Strategies (‘tips’) to optimize resilience and wellbeing with an integrative resilience approach of individual, learning environment, and organization/systems factors are presented.     

The education avenue of the clinical learning environment: A pragmatic approach

Abstract

Aim: This perspective is part of a series of articles that are outcomes of a consensus conference, that seek to offer a comprehensive examination of the clinical learning environment (CLE), using different academic disciplines and areas of focus termed “avenues.” The education dimensions of the CLE are discussed in detail in this perspective, along with critical linkages to the other avenues.

Methods: Using iterative presentations, discussion and small group work, in October 2018, the consensus conference participants explored the education, psychological, sociocultural, diversity and inclusion, digital and architectural aspects of the CLE.

Results: The education avenue of the CLE includes elements of teaching and learning such as the curriculum, clinical experiences, the assessment system, educational program governance, trainee selection, faculty development, and program evaluation and improvement. Within the educational domain, we focus on organizational and personal/social aspects of the CLE, including (1) curriculum design and deployment, including placement of trainees in clinical settings, organizational culture, practices and policies, and accreditation and regulatory requirements from the organizational domain (2) the education system, including assessment, program evaluation and organization and governance; and (3) elements from the personal and social domains, including peer-to-peer, trainee-faculty, and trainee-patient relationships that influence how and what postgraduate trainees learn, trainee selection, informal and hidden curricula, and trainees’ perceptions of their learning environment.

Conclusions: We provide suggestions for further research and recommendations for addressing challenges and facilitating improvement in the educational aspects of the CLE, along with actionable practice points.     

A unique flipped classroom approach shows promising results in physician assistant education

Abstract

Aims: The flipped classroom (FC) model utilizes pre-class foundational learning with in-class higher-order application exercises. FC approaches have reported positive perceptions and mixed academic performance outcomes in medical education; however, little evidence exists on their impact in the 56-week didactic curriculum of Physician Assistant (PA) education.

Methods: A 4-week FC curriculum was piloted in a PA behavioral medicine course (n?=?34). Before class, students completed online video modules. During class, students completed a pre-class quiz and answered clinical case-based questions in a think-pair-share format.

Results: Students rated in-class time higher than a lecture-based segment of the same course (p?=?0.028). Assessment of achievement emotions demonstrated increased enjoyment (p?=?0.028) and decreased boredom (p?<?0.001) in the FC curriculum with no difference in anxiety. The FC curriculum produced a 57.2?min increase in pre-class preparation time with no change in post-class studying time. Compared to historical lecture-based controls (n?=?35), students in the FC curriculum scored significantly higher on clinical vignette questions (p?=?0.019) with equivalent performance on other question formats.

Conclusions: This study offers the first positive outcomes of an FC approach in PA education and provides a framework for improving academic performance while scaling back in-class time.