Learning in a High-Stress Clinical Environment: Stressors Associated with Medical Students’ Clerkship Training on Labor and Delivery

Abstract

Phenomenon: Obstetrics and gynecology can be a high-stress clinical environment for medical students due to the specialty’s fast-paced and unpredictable nature. Little is known about learning stressors for medical students on the obstetrics and gynecology clerkship to inform stress-reducing interventions and improve learning experience. This study investigated (a) which aspects of the learning environment are most stressful for obstetrics and gynecology clerkship students, (b) how perceived learning stressors in this environment differ for medical students and teachers (residents, fellows, and faculty), and (c) what interventions students propose to address these stressors. Approach: From May 2015 to April 2016, we conducted semistructured individual interviews with 3rd-year medical students from obstetrics and gynecology clerkship cohorts (n?=?52) as well as clerkship teachers (n?=?10) at an academic medical center. Two investigators used a qualitative Framework Method approach to analyze the interview data and agree upon final themes. Findings: We identified labor and delivery as the most stressful learning environment and four labor and delivery–related themes of students’ learning stressors: context (pace, logistics, nature of childbirth, and nonroutine schedule), learning tasks (student role and assignments and the amount of new knowledge and skills), communication (terminology used in conversation and interacting with the labor and delivery team), and clinical scenario (crisis, emergency, and patient refusal of student involvement). Whereas students identified context as causing most of the stress, teachers concentrated on stressors related to learning tasks. Insights: Learning stressors associated with students’ educational experience in the clinical context of labor and delivery are challenging for medical students. In addition to the specific content of these challenges, the recognition that teachers’ assumptions about sources of stressors are different from those of students is an important finding and has implications for changing the learning environment. Clerkship programs are encouraged to provide practical guidelines and embed an introduction of the clinical learning environment into the Obstetrics and Gynecology clerkship orientation curriculum.     

Mind–Body Skills Training to Improve Distress Tolerance in Medical Students: A Pilot Study

Problem: Medical students face rigorous and stressful work environments, resulting in high rates of psychological distress. However, there has been a dearth of empirical work aimed at modifying risk factors for psychopathology among this at-risk group. Distress tolerance, defined as the ability to withstand emotional distress, is one factor that may be important in promoting psychological well-being in medical students. Thus, the aim of the current mixed-methods study was (a) to describe changes in facets of distress tolerance (i.e., emotional tolerance, absorption, appraisal, regulation) for medical students who completed a mind–body skills training group, and a no-intervention control group of students; (b) to examine the relationship between changes in psychological variables and changes in distress tolerance; and (c) to report students' perceptions of the mind–body group, with an emphasis on how the group may have affected personal and professional functioning due to improvements in distress tolerance. Intervention: The mind–body program was an 11-week, 2-hour skills training group that focused on introducing, practicing, and processing mind–body skills such as biofeedback, guided imagery, relaxation, several forms of meditation (e.g., mindfulness), breathing exercises, and autogenic training. Context: Participants were 52 first- and second-year medical students (62.7% female, M_age = 23.45, SD = 1.51) who participated in a mind–body group or a no-intervention control group and completed self-report measures before and after the 11-week period. Outcome: Students in the mind–body group showed a modest improvement in all distress tolerance subscales over time (ΔM = .42–.53, p = .01–.03, d = .44–.53), whereas the control group showed less consistent changes across most subscales (ΔM = .11–.42, p = .10–.65, d = .01–.42). Students in the mind–body group qualitatively reported an improved ability to tolerate affective distress. Overall, improvements in psychological symptoms were associated with improvements in distress tolerance in the mind–body group but not in the control group. Lessons Learned: These preliminary findings provide support for the notion that improving distress tolerance through mind–body skills training might serve to protect medical students from becoming functionally impaired by psychological distress. Thus, implementing mind–body skills training into medical school education may help to improve the psychological well-being of medical students. Future studies utilizing more methodologically rigorous designs are warranted.     

Medical Outcomes Study Short Form 36: a possible source of utilities?

General health-status questionnaires such as the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) are frequently used to measure health-related quality of life. The SF-36, in its current form, cannot be used to measure individuals' utilities or preferences for their health state. Recently, several investigators have explored the possibility of obtaining utilities from the SF-36. This article reviews the SF-36 survey, selected measures of utility, and the differences between health-status and utility measures, with an emphasis on use of SF-36 results to derive utility scores. We searched the literature from January 1966 to July 1999 using MEDLINE and HEALTHSTAR. The terms SF-36, health-status instruments, utilities, and preferences were searched to identify studies that had used both the SF-36 and a utility-based instrument. We first discuss studies that were specifically designed to find a predictive equation to obtain utilities from SF-36 scores. We then discuss studies that examined the correlation between the SF-36 and a utility-based instrument but that were not intended to develop a predictive equation as their primary objective. The studies that have tried to derive utilities from the SF-36 using a predictive equation have used different methodologies; to date, no reliable method has been appropriately validated. The poor correlation reported in most of the studies attests to the complex relationship between utility-based instruments and the SF-36. More work is needed to elucidate if utilities can be obtained from the SF-36.     

Team Science Approach to Developing Consensus on Research Good Practices for Practice‐Based Research Networks: A Case Study

Using peer learning strategies, seven experienced PBRNs working in collaborative teams articulated procedures for PBRN Research Good Practices (PRGPs). The PRGPs is a PBRN‐specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings. This paper describes the team science processes which culminated in the PRGPs. Skilled facilitators used team science strategies and methods from the Technology of Participation (ToP®), and the Consensus Workshop Method to support teams to codify diverse research expertise in practice‐based research. The participatory nature of “sense‐making” moved through identifiable stages. Lessons learned include (1) team input into the scope of the final outcome proved vital to project relevance; (2) PBRNs with diverse domains of research expertise contributed broad knowledge on each topic; and (3) ToP® structured facilitation techniques were critical for establishing trust and clarifying the “sense‐making” process.     

Clinical Application of a Robotic Ankle Training Program for Cerebral Palsy Compared to the Research Laboratory Application: Does It Translate to Practice?

Objective

To determine the clinical efficacy of an ankle robotic rehabilitation protocol for patients with cerebral palsy.

Design

The clinic cohort was identified from a retrospective chart review in a before-after intervention trial design and compared with a previously published prospective research cohort.

Setting

Rehabilitation hospital.

Participants

Children (N=28; mean age, 8.2±3.62y) with Gross Motor Function Classification System levels I, II, or III who were referred for ankle stretching and strengthening used a robotic ankle device in a clinic setting. Clinic results were compared with a previously published cohort of participants (N=12; mean age, 7.8±2.91y) seen in a research laboratory-based intervention protocol.

Interventions

Patients in the clinic cohort were seen 2 times per week for 75-minute sessions for a total of 6 weeks. The first 30 minutes of the session were spent using the robotic ankle device for ankle stretching and strengthening, and the remaining 45 minutes were spent on functional movement activities. There was no control group.

Main Outcome Measures

We compared pre- and postintervention measures of plantarflexor and dorsiflexor range of motion, strength, spasticity, mobility (Timed Up and Go test, 6-minute walk test, 10-m walk test), balance (Pediatric Balance Scale), Selective Control Assessment of the Lower Extremity (SCALE), and gross motor function measure (GMFM).

Results

Significant improvements were found for the clinic cohort in all main outcome measures except for the GMFM. These improvements were equivalent to those reported in the research cohort, except for larger SCALE test changes in the research cohort.

Conclusions

These findings suggest that translation of repetitive, goal-directed biofeedback training into the clinic setting is both feasible and beneficial for patients with cerebral palsy.     

Mentoring in Clinical‐Translational Research: A Study of Participants in Master's Degree Programs

Research projects in translational science are increasingly complex and require interdisciplinary collaborations. In the context of training translational researchers, this suggests that multiple mentors may be needed in different content areas. This study explored mentoring structure as it relates to perceived mentoring effectiveness and other characteristics of master''s‐level trainees in clinical‐translational research training programs. A cross‐sectional online survey of recent graduates of clinical research master''s program was conducted. Of 73 surveys distributed, 56.2% (n = 41) complete responses were analyzed. Trainees were overwhelmingly positive about participation in their master''s programs and the impact it had on their professional development. Overall the majority (≥75%) of trainees perceived they had effective mentoring in terms of developing skills needed for conducting clinical‐translational research. Fewer trainees perceived effective mentoring in career development and work‐life balance. In all 15 areas of mentoring effectiveness assessed, higher rates of perceived mentor effectiveness was seen among trainees with ≥2 mentors compared to those with solo mentoring (SM). In addition, trainees with ≥2 mentors perceived having effective mentoring in more mentoring aspects (median: 14.0; IQR: 12.0–15.0) than trainees with SM (median: 10.5; IQR: 8.0–14.5). Results from this survey suggest having ≥2 mentors may be beneficial in fulfilling trainee expectations for mentoring in clinical‐translational training.     

Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years

Problem: Medical educators, clinicians, and health policy experts widely acknowledge the need to increase the diversity of our healthcare workforce and build our capacity to care for medically underserved populations and reduce health disparities. Intervention: The Program in Medical Education for the Urban Underserved (PRIME-US) is part of a family of programs across the University of California (UC) medical schools aiming to recruit and train physicians to care for underserved populations, expand the healthcare workforce to serve diverse populations, and promote health equity. PRIME-US selects medical students from diverse backgrounds who are committed to caring for underserved populations and provides a 5-year curriculum including a summer orientation, a longitudinal seminar series with community engagement and leadership-development activities, preclerkship clinical immersion in an underserved setting, a master's degree, and a capstone rotation in the final year of medical school. Context: This is a mixed-methods evaluation of the first 4 years of the PRIME-US at the UC Berkeley–UC San Francisco Joint Medical Program (JMP). From 2006 to 2010, focus groups were conducted each year with classes of JMP PRIME-US students, for a total of 11 focus groups; major themes were identified using content analysis. In addition, 4 yearly anonymous, online surveys of all JMP students, faculty and staff were conducted and analyzed. Outcome: Most PRIME-US students came from socioeconomically disadvantaged backgrounds and ethnic backgrounds underrepresented in medicine, and all were committed to caring for underserved populations. The PRIME-US students experienced many program benefits including peer support, professional role models and mentorship, and curricular enrichment activities that developed their knowledge, skills, and sustained commitment to care for underserved populations. Non-PRIME students, faculty, and staff also benefited from participating in PRIME-sponsored seminars and community-based activities. Challenges noted by PRIME-US students and non-PRIME students, faculty, and staff included the stress of additional workload, perceived inequities in student educational opportunities, and some negative comments from physicians in other specialties regarding primary care careers. Lessons Learned: Over the first 4 years of the program, PRIME-US students and non-PRIME students, faculty, and staff experienced educational benefits consistent with the intended program goals. Long-term evaluation is needed to examine the participants' medical careers and impacts on California's healthcare workforce and patient outcomes. Attention should also be paid to the challenges of implementing new medical education enrichment programs.     

The Handbook of Clinical Trials and Other Research Alan Earl‐SlaterRadcliffe Medical Press. ISBN: 1‐857‐75485‐9, 2002, 352 pp., £29.95

Introduction and aims: Despite a wealth of literature looking at how families cope when a member has a drinking problem, little is known about the experiences of male partners. This study sought to redress this balance by exploring coping behaviours in male partners of female problem drinkers.

Participants: Male partners (n = 29) were recruited through female problem drinkers who were in contact with one of three specialist alcohol services.

Design: Male partners completed a self‐report questionnaire. This included the Coping Questionnaire (Orford, ), which has been found to contain three factors of coping behaviour: engaged, tolerant‐inactive and withdrawal.

Results: Contrary to what was expected, male partners reported using engaged coping behaviours most frequently and withdrawal coping behaviours least frequently. Significant positive correlations were found between the males' coping behaviours, and both the length of the problem drinking and the extent to which they saw their partners' drinking as problematic.

Conclusions: The results gave little support to the idea that males withdraw from females with drinking problems, and the males reported to be engaged in both an active and controlling way in trying to cope with their partner's drinking. The results reinforce the need to include a female's significant others in the treatment of her alcohol problem.     

A Social Network Analysis of 140 Community‐Academic Partnerships for Health: Examining the Healthier Wisconsin Partnership Program

Introduction:

Social Network Analysis (SNA) provides an important, underutilized approach to evaluating Community Academic Partnerships for Health (CAPHs). This study examines administrative data from 140 CAPHs funded by the Healthier Wisconsin Partnership Program (HWPP).

Methods:

Funder data was normalized to maximize number of interconnections between funded projects and 318 non‐redundant community partner organizations in a dual mode analysis, examining the period from 2003–2013.Two strategic planning periods, 2003–2008 vs. 2009–2014, allowed temporal comparison.

Results:

Connectivity of the network was largely unchanged over time, with most projects and partner organizations connected to a single large component in both time periods. Inter‐partner ties formed in HWPP projects were transient. Most community partners were only involved in projects during one strategic time period. Community organizations participating in both time periods were involved in significantly more projects during the first time period than partners participating in the first time period only (Cohen''s d = 0.93).

Discussion:

This approach represents a significant step toward using objective (non‐survey) data for large clusters of health partnerships and has implications for translational science in community settings. Considerations for government, funders, and communities are offered. Examining partnerships within health priority areas, orphaned projects, and faculty ties to these networks are areas for future research.     

Promotion and Tenure for Community‐Engaged Research: An Examination of Promotion and Tenure Support for Community‐Engaged Research at Three Universities Collaborating through a Clinical and Translational Science Award

Introduction

Community‐engaged health research, an approach to research which includes the participation of communities, promotes the translation of research to address and improve social determinants of health. As a way to encourage community‐engaged research, the National Institutes of Health required applicants to the Clinical and Translational Science Award (CTSA) to include a community engagement component. Although grant‐funding may support an increase in community‐engaged research, faculties also respond to the rewards and demands of university promotion and tenure standards. This paper measures faculty perception of how three institutions funded by a CTSA support community‐engaged research in the promotion and tenure process.

Methods

At three institutions funded by a CTSA, tenure track and nontenure track faculty responded to a survey regarding perceptions of how promotion and tenure committees value community‐engaged research.

Results

Faculty view support for community‐engaged research with some reserve. Only 36% agree that community‐engaged research is valued in the promotion and tenure process.

Discussion

Encouraging community‐engaged scholarship requires changing the culture and values behind promotion and tenure decisions. Institutions will increase community‐engaged research and more faculty will adopt its principles, when it is rewarded by promotion and tenure committees.     

Medical Student Education in Emergency Medicine: Do Students Meet the National Standards for Clinical Encounters of Selected Core Conditions?

Background

Establishing a core curriculum for undergraduate Emergency Medicine (EM) education is crucial to development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommended that all students in a 4^th-year EM clerkship be exposed to 10 emergent clinical conditions.

Objectives

To evaluate the feasibility of encountering recommended core conditions in a clinical setting during a 4^th-year EM clerkship.

Methods

Students from three institutions participated in this ongoing, prospective observation study. Students' patient logs were collected during 4-week EM clerkships between July 2011 and June 2012. De-identified logs were reviewed and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the core complaints was calculated, as was the average number of core complaints seen by each.

Results

Data from 130 students at three institutions were captured; 15.4% of students saw all 10 conditions during their rotation, and 76.9% saw at least eight. The average number of conditions seen per student was 8.4 (range of 7.0–8.6). The percentage of students who saw each condition varied, ranging from 100% (chest pain and abdominal pain) to 31% (cardiac arrest).

Conclusions

Most students do not encounter all 10 conditions during patient encounters throughout a 4-week EM rotation, although most have exposure to at least eight. Certain conditions are far less likely than others to be encountered, and may need to be taught in a nonclinical setting.     

Association of biochemical values with morbidity in the elderly: a population‐based Swedish study of persons aged 82 or more years

Background: Various inter‐dependent factors influence serum biochemical values. In the elderly, the impact of these factors may differ compared with younger age groups and therefore population‐based studies among older people are needed. The specific morbidity in old age, including also various types of drug therapy, should be observed. Methods: Various biochemical tests in 349 females and 186 males over 81 years of age were carried out and the associations of biochemical values with morbidity, drug therapy, anthropometry and gender were estimated. Results: Biochemical serum values deviate in various diseases, characterized by increased frequency in the elderly, i.e. congestive heart failure, osteoporosis, hip fractures, depression and dementia. All of these diseases present a tendency to increased homocysteine, usually combined with low folate. Cases with intact cognitive function throughout the six years after sampling are characterized by low homocysteine, which is the opposite of what is found in dementia. Furthermore, congestive heart failure is associated with impaired creatinine clearance and increased urea and urate, and osteoporosis and hip fractures are characterized by low albumin and cholesterol. Increased values for urate and impaired creatinine clearance are found in coronary diseases. In gout, multiple biochemical changes take place. For cases with a history of diabetes, arterial hypertension, peptic ulcer and malignancy, few changes are found compared with the values of the total sample. Furosemide therapy is associated with the same pattern as congestive heart failure, and laxative treatment is characterized by low folate and high homocysteine values.     

Challenges and Opportunities for Clinical Pharmacogenetic Research Studies in Resource-limited Settings: Conclusions From the Council for International Organizations of Medical Sciences–Ibero-American Network of Pharmacogenetics and Pharmacogenomics Meeting

PurposeThe symposium Health and Medicines in Indigenous Populations of America was organized by the Council for International Organizations of Medical Sciences (CIOMS) Working Group on Clinical Research in Resource-Limited Settings (RLSs) and the Ibero-American Network of Pharmacogenetics and Pharmacogenomics (RIBEF). It was aimed to share and evaluate investigators' experiences on challenges and opportunities on clinical research and pharmacogenetics.MethodsA total of 33 members from 22 countries participated in 2 sessions: RIBEF studies on population pharmacogenetics about the relationship between ancestry with relevant drug-related genetic polymorphisms and the relationship between genotype and phenotype in Native Americans (session 1) and case examples of clinical studies in RLSs from Asia (cancer), America (diabetes and women health), and Africa (malaria) in which the participants were asked to answer in free text their experiences on challenges and opportunities to solve the problems (session 2). Later, a discourse analysis grouping common themes by affinity was conducted.FindingsThe main result of session 1 was that the pharmacogenetics-related ancestry of the population should be considered when designing clinical studies in RLSs. In session 2, 21 challenges and 20 opportunities were identified. The social aspects represent the largest proportion of the challenges (43%) and opportunities (55%), and some of them seem to be common.ImplicationsThe main discussion points were gathered in the Declaration of Mérida/T'Hó and announced on the Parliament of Extremadura during the CIOMS-RIBEF meeting in 4 of the major Latin American autochthonous languages (Náhualth, Mayan, Miskito, and Kichwa). The declaration highlighted the following: (1) the relevance of population pharmacogenetics, (2) the sociocultural contexts (interaction with traditional medicine), and (3) the education needs of research teams for clinical research in vulnerable and autochthonous populations.