Abstract: Although incorporating cost-considerations during healthcare decision-making is increasingly important to American patients and physicians, content related to these constructs is not routinely included in medical education. As a result, physicians are ill-equipped to consider costs. This study sought input from practicing physicians on perceived deficiencies in current teaching and recommendations for necessary content to include in medical teaching. We conducted a qualitative descriptive study using semi-structured interviews utilizing a purposeful maximum variation sample of cardiologists and neonatologists practicing in diverse settings. We analyzed interviews using conventional content analysis. 18 cardiologists and 17 neonatologists participated in this study. Respondents perceived that current teaching does not impart sufficient knowledge of value and cost considerations to achieve patient-centered, high-value decision-making. They identified the following priority areas for education related to healthcare costs: the business of medicine and information about out-of-pocket patient costs, training in health research interpretation skills to critically appraise evidence, and communication skills to engage patients as partners in shared decision-making. Participants recommended a variety of teaching methods, including didactic sessions on core topics, role modeling and case studies. American physicians perceive learning needs related to the incorporation of costs into clinical decision-making that can inform curriculum development initiatives in this field. Physicians perceive knowledge of these topics and skills to be crucial to achieving patient-centered high-value care. Concomitant health system reforms supporting the needs of the patient at its center are essential to enable physicians to focus on a patient-centered approach to healthcare delivery. PubDate: 2019-05-29
Abstract: Evidenced by leading journals in academic medicine, health professions education has taken up the call to advance equitable healthcare. One pressing area where gaps and inequities are apparent is transgender (trans) people’s access to gender-affirming medicine such as hormones and surgeries. Reasons for the dire state of care include education gaps. While specific content knowledge has been identified as lacking in medical school curricula, less research has focused on the complex social practices required of clinicians and educators working in gender-affirming medicine, and how these skills are learned through practice. In order to inform health professions education in this key area of need, we conducted a study to better understand the social practices, and the learning that occurs therein, of gender-affirming medicine. We identified the work processes of 22 clinicians, clinician-educators, trans patients, and clinical care administrators with attention to how policies and protocols influenced practice, learning, and teaching. The results of our study elucidate: (1) that practicing of gender-affirming medicine is strictly dictated by standardized assessment protocols, which serve as a form of curriculum; and (2) how health professionals learn and teach health advocacy as a form of resistance to protocols identified as creating inequities. These findings suggest an opportunity to view protocols—and their inherent limitations—more deliberately as teaching and learning tools, specifically for learning advocacy. PubDate: 2019-05-28
Abstract: Many models of safe and effective clinical decision making in medical practice emphasize the importance of recognizing moments of uncertainty and seeking help accordingly. This is not always done effectively, but we know little about what cues prompt health professionals to call on resources beyond their own knowledge or skill set. Such information would offer guidance regarding how systems might be designed to offer better individual support. In this study, the authors explored the situational factors that are present during moments of uncertainty that lead primary care physicians to access external resources. To do so, a generic qualitative exploratory analysis was conducted on 72 narratives collected through audio recorder-based, self-observational, journaling completed by 12 purposively selected family physicians. Participants were asked to provide a detailed descriptive account of the circumstances surrounding their consultation of external resources immediately after 6 sequential patient encounters in which they felt compelled to seek such support. Thematic analysis of the transcripts was performed to better understand participants’ experiences of the social, contextual, and personal features surrounding decisions to seek support. When doing so we observed that specific features of patient encounters were routinely present when physicians decided to access external sources for help. These included medical aspects of the case (e.g., complex presentations), social aspects (e.g., the presence of another individual), and personal factors (e.g., feeling a need for reassurance). External resources were seen as an opportunity for verification, a mechanism to increase patient satisfaction, and a means through which to defend decision-making. Accessing such resources appeared to influence the physician–patient relationship for various reasons. Recognition and further study of the cues that prompt use of external information will further our understanding of physicians’ behavioural responses to challenging/uncertain situations, highlight mechanisms through which a culture of self-directed assessment seeking might be encouraged, and offer guidance regarding ways in which physicians can be encouraged to practice mindfully. Our results make it clear that reasons for which primary care physicians seek the support of external resources may be multifactorial and, therefore, one should be cautious when inferring reasons for the pursuit of such support. PubDate: 2019-05-23
Abstract: To be safe and effective practitioners and learners, medical professionals must be able to accurately assess their own performance to know when they need additional help. This study explored the metacognitive judgments of 157 first-year medical students; in particular, the study examined students’ self-assessments or calibration as they engaged in a virtual-patient simulation targeting clinical reasoning practices. Examining two key subtasks of a patient encounter, history (Hx) and physical exam (PE), the authors assessed the level of variation in students’ behavioral performance (i.e., effectiveness and efficiency) and judgments of performance (i.e., calibration bias and accuracy) across the two subtasks. Paired t tests revealed that the Hx subtask was deemed to be more challenging than the PE subtask when viewed in terms of both actual and perceived performance. In addition to students performing worse on the Hx subtask than PE, they also perceived that they performed less well for Hx. Interestingly, across both subtasks, the majority of participants overestimated their performance (98% of participants for Hx and 95% for PE). Correlation analyses revealed that the participants’ overall level of accuracy in metacognitive judgments was moderately stable across the Hx and PE subtasks. Taken together, findings underscore the importance of assessing medical students’ metacognitive judgments at different points during a clinical encounter. PubDate: 2019-05-16
Abstract: Productive failure is an instructional approach that requires learners to struggle as they attempt to generate solutions to problems before, rather than after, receiving direct instruction on a targeted concept. Studies demonstrate that productive failure prepares students for later learning of new, related knowledge. Our study explored the effectiveness of productive failure as an instructional intervention in health professions education with respect to (a) acquisition and application of a novel concept, and (b) learners’ preparation for future learning of new, related content. Forty year-one students enrolled in the Doctor of Pharmacy program at the University of Toronto were randomly assigned to a productive failure (i.e. attempt to generate solutions before receiving instruction) or direct instruction only learning condition. After a practice phase, participants completed a series of tests designed to measure knowledge acquisition, knowledge application, and preparation for future learning (new learning is required for successful problem solving). As expected, no difference in performance was seen between participants on the acquisition and application tests. However, participants in the productive failure condition outperformed those in the direct instruction condition on the preparation for future learning test. These results emphasize the role of struggle in learning and support the theory that engaging students in solving problems that are beyond their abilities can be a productive exercise in failure. The results suggest that productive failure assists learners in acquiring the conceptual knowledge needed to facilitate learning in the future. PubDate: 2019-05-14
Abstract: Health professions education scholarship units (HPESUs) are increasingly becoming a standard for medical schools worldwide without having much information about their value and role in actual educational practices, particularly of those who work in these units, the educational scientists. We conducted a linguistic analysis, called Membership Categorization Analysis, of interviews with leaders of recent curriculum changes to explore how they talk about educational scientists in relation to these processes. The analysis was conducted on previously collected interview data with nine change leaders of major undergraduate medical curriculum change processes in the Netherlands. We analyzed how change leaders categorize HPESUs and educational scientists (use of category terms) and what they say about them (predicates). We noticed two ways of categorizing educational scientists, with observable different predicates. Educational scientists categorized by their first name were suggested to be closer to the change process, more involved in decisional practices and positively described, whereas those described in more generic terms were represented in terms of relatively passive and unspecified activities, were less explicit referenced for their knowledge and expertise and were predominantly factually or negatively described. This study shows an ambiguous portrayal of educational scientists by leaders of major curriculum change processes. Medical schools are challenged to establish medical curricula in consultation with a large, diverse and interdisciplinary stakeholder group. We suggest that it is important to invest in interpersonal relationships to strengthen the internal collaborations and make sure people are aware of each other’s existence and roles in the process of curriculum development. PubDate: 2019-05-08
Abstract: Student participation in governance of education is of growing interest. However, it remains unclear what factors render this participation in institutional governance a success or a failure. Another question is: what are the perceived benefits for schools and students' We empirically explored experiences and perspectives of student representatives and program directors of all (8) medical and (1) veterinary schools in the Netherlands on factors that influence student participation in institutional governance and its values and challenges for schools and student representatives. A constructivist grounded theory study was performed. A theoretical sample of student representatives was invited to fill out an explorative, qualitative questionnaire. Next, focus groups with student representatives and interviews with all program directors were conducted. Data was analyzed using open, axial and selective coding by all authors. Experiences and perspectives of students and program directors were remarkably similar in both perceived influences and values. Four main categories of influences could be distinguished in student participation: (1) individual student characteristics, (2) individual staff characteristics, (3) the organization of student representatives and (4) the school’s organization, including its culture and policy regarding student participation. A cohesive, well-organized and independent student organization has crucial impact on student participation in educational governance processes. For representatives, major benefits of participation are personal and career development. Challenges are low effectiveness and efficiency of their actions. A clear school policy on student participation and better introduction, feedback and coaching of representatives should be provided to improve student participation in governance processes. PubDate: 2019-05-01
Abstract: Medicine in the twenty-first century faces an ‘identity crisis,’ as it grapples with the emergence of various ‘ways of knowing,’ from evidence-based and translational medicine, to narrative-based and personalized medicine. While each of these approaches has uniquely contributed to the advancement of patient care, this pluralism is not without tension. Evidence-based medicine is not necessary individualized; personalized medicine may be individualized but is not necessarily person-centered. As novel technologies and big data continue to proliferate today, the focus of medical practice is shifting away from the dialogic encounter between doctor and patient, threatening the loss of humanism that many view as integral to medicine’s identity. As medical trainees, we struggle to synthesize medicine’s diverse and evolving ‘ways of knowing’ and to create a vision of doctoring that integrates new forms of medical knowledge into the provision of person-centered care. In search of answers, we turned to twentieth-century philosopher Hans-Georg Gadamer, whose unique outlook on “health” and “healing,” we believe, offers a way forward in navigating medicine’s ‘messy pluralism.’ Drawing inspiration from Gadamer’s emphasis on dialogue and ‘practical wisdom’ (phronesis), we initiated a dialogue with the dean of our medical school to address the question of how medical trainees and practicing clinicians alike can work to create a more harmonious pluralism in medicine today. We propose that implementing a pluralistic approach ultimately entails ‘bridging’ the current divide between scientific theory and the practical art of healing, and involves an iterative and dialogic process of asking questions and seeking answers. PubDate: 2019-05-01
Abstract: An optimal learning climate is crucial for the quality of residency training and may also improve residents’ well-being and empathy. We investigated the associations of learning climate with residents’ work-related well-being. A multicenter questionnaire study was performed among 271 surgery and gynaecology residents in 21 training programs from September 2012 to February 2013. Residents were asked to complete work-related well-being measurements: work engagement (Utrecht Work Engagement Scale), job and specialty satisfaction (measures from Physician Worklife Study), and physician empathy (Jefferson Scale of Physician Empathy). The Dutch Residency Educational Climate Test was used to evaluate learning climate. Multivariate adjusted linear regression analyses were used to estimate associations of learning climate with work-related well-being measures. Well-being measures were completed by 144 residents (53.1%). Learning climate was evaluated by 193 residents, yielding 9.2 evaluations per training program on average. Overall learning climate score was positively associated with work engagement [regression coefficient b = 0.58; 95% confidence interval (CI) 0.18–0.98; p = 0.004] and job satisfaction (b = 0.80; 95% CI 0.48–1.13; p < 0.001). No associations were found between learning climate and empathy and specialty satisfaction. Residents’ work engagement and job satisfaction are positively related to the learning climate and may be further enhanced by improved learning climates of training programs. PubDate: 2019-05-01
Abstract: Dropping out from undergraduate medical education is costly for students, medical schools, and society in general. Therefore, the early identification of potential dropout students is important. The contribution of personal features to dropout rates has merited exploration. However, there is a paucity of research on aspects of student experience that may lead to dropping out. In this study, underpinned by theoretical models of student commitment, involvement, and engagement, we explored the hypothesis of using inferior participation as an indicator of a higher probability of dropping out in year 1. Class participation was calculated as an aggregate score based on teachers’ daily observations in class. The study used a longitudinal dataset of six cohorts of high-school entry students (N = 709, 67% females) in one medical school with an annual intake of 120 students. The findings confirmed the initial hypothesis and showed that lower scores of class participation in year 1 added predictive ability to pre-entry characteristics (Pseudo-R2 raised from 0.22 to 0.28). Even though the inclusion of course failure in year 1 resulted in higher explanatory power than participation in class (Pseudo-R2 raised from 0.28 to 0.63), ratings of class participation may be advantageous to anticipate dropout identification, as those can be collected prior to course failure. The implications for practice are that teachers’ ratings of class participation can play a role in indicating medical students who may eventually drop out. We conclude that the scores of class participation can contribute to flagging systems for the early detection of student dropouts. PubDate: 2019-05-01
Abstract: The aim of this study was to explore challenging encounters experienced by registered nurses (RN) during their first year in the emergency medical service by using the social learning theory of communities of practice. During the first year in a new professional practice, a new RN experiences a transition during which the new professional identity is being formed. This is a challenging and demanding period of time. According to the learning theory of communities of practice by Lave and Wenger, individuals’ learning and development in a new professional practice occurs through participation in social activity and is influenced by context. This study is based on the qualitative data from semi-structured interviews. Thirty-two RNs working in the Swedish emergency medical service were interviewed via telephone during the spring of 2017. A qualitative content analysis with deductive reasoning of the interviews was used. The analysis process generated the main category; New RNs participation is challenged by unpredictability and uncertainty in practice. The main category was based on three generic categories; Loneliness in an unpredictable context, Uncertainty about the team, and Uncertainty in action. The challenges new RNs encounter during the first year relate to all three dimensions of a community of practice; mutual engagement, joint enterprise and shared repertoire. The encountered challenges also relate to the EMS context. Taking into account all these aspects when designing support models for RN’s professional development may be advantageous for creating positive development for RNs new to the EMS and/or similar practices. PubDate: 2019-05-01
Abstract: Previous research highlighted associations between students’ motivation for medical studies and their learning approaches on the one hand and empathy on the other. Internal motivational factors for studying medicine (e.g., care for patients, save lives) coupled with a deep approach to learning have been positively related to empathy in contrast to external motivational factors (e.g., future earning potential, prestige) and surface learning. However, assessments of these assumptions among medical school candidates are scarce. This study examined the relationship between different motivational factors and empathy among students enrolled in a selection year in medicine by testing the mediating role of learning approaches. A sample of 572 candidates for medical studies answered a self-reported questionnaire half way through their selection year. Measures included internal and external motivational factors for studying medicine, deep and surface learning approaches and empathy. Path-analysis tested the mediation effects of deep and surface approaches to learning on the relationship of internal and external motivational factors with empathy. The deep learning approach partially mediated the significant positive association between internal motivational factors and empathy, while the surface learning approach fully mediated the significant negative association between external motivational factors and empathy. These results suggest that learning approaches could be a pathway by which internal and external motives for studying medicine are related to empathy among medical school candidates. Pedagogical strategies and educational environments accounting for individual differences in motivation and learning may contribute to training students to become professional and caring doctors in the future. PubDate: 2019-05-01
Abstract: The present study aims at fostering undergraduate medical students’ clinical reasoning by learning from errors. By fostering the acquisition of “negative knowledge” about typical cognitive errors in the medical reasoning process, we support learners in avoiding future erroneous decisions and actions in similar situations. Since learning from errors is based on self-explanation activities, we provided additional prompting procedures to foster the effectiveness of the error-based instructional approach. The extent of instructional support in a web-based learning environment with erroneous clinical case examples was varied in a one-factorial design with three groups by either presenting the cases as (a) unsupported worked examples or by providing the participants with (b) closed prompts in the form of multiple-choice tasks or (c) with open reflection prompts during the learning process. Despite significant learning progress in all conditions, neither prompting procedure improved the learning outcomes beyond the level of the unsupported worked example condition. In contrast to our hypotheses, the unsupported worked example condition was the most effective with respect to fostering clinical reasoning performance. The effects of the learning conditions on clinical reasoning performance was mediated by cognitive load, and moderated by the students’ self-efficacy. Both prompting procedures increased extraneous cognitive load. For learners with low self-efficacy, the prompting procedures interfered with effective learning from errors. Although our error-based instructional approach substantially improved clinical reasoning, additional instructional measures intended to support error-based learning processes may overtax learners in an early phase of clinical expertise development and should therefore only be used in moderation. PubDate: 2019-05-01
Abstract: Self-regulated learning is optimized when instructional supports are provided. We evaluated three supports for self-regulated simulation-based training: practice schedules, normative comparisons, and learning goals. Participants practiced 5 endoscopy tasks on a physical simulator, then completed 4 repetitions on a virtual reality simulator. Study A compared two practice schedules: sequential (master each task in assigned order) versus unstructured (trainee-defined). Study B compared normative comparisons framed as success (10% of trainees were successful) versus failure (90% of trainees were unsuccessful). Study C compared a time-only goal (go 1 min faster) versus time + quality goal (go 1 min faster with better visualization and scope manipulation). Participants (18 surgery interns, 17 research fellows, 5 medical/college students) were randomly assigned to groups. In Study A, the sequential group had higher task completion (10/19 vs. 1/21; P < .001), longer persistence attempting an ultimately incomplete task (20.0 vs. 15.9 min; P = .03), and higher efficiency (43% vs. 27%; P = .02), but task time was similar between groups (20.0 vs. 22.6 min; P = .23). In Study B, the success orientation group had higher task completion (10/16 vs. 1/24; P < .001) and longer persistence (21.2 vs. 14.6 min; P = .001), but efficiency was similar (33% vs. 35%; P = .84). In Study C, the time-only group had greater efficiency than time + quality (56% vs. 41%; P = .03), but task time did not differ significantly (172 vs. 208 s; P = .07). In this complex motor task, a sequential (vs. unstructured) schedule, success (vs. failure) orientation, and time-only (vs. time + quality) goal improved some (but not all) performance outcomes. PubDate: 2019-05-01
Abstract: Financial support for institutional research is relatively stagnant, and thus institutions are likely to seek tuition revenue to offset the costs of research and teaching. It is likely that this has led to increases in tuition driven activities, and thus has limited research activities of academic physical therapy (PT) programs in particular. However, the relationships between sources of program revenue, the number of graduates from PT programs, and the scholarly production of PT faculty have not been studied. The purpose of this paper is to study the effects of types of funding—including research grants and tuition—on the number of physical therapy graduates from each program and the research productivity of physical therapy faculty. Data from 2008 to 2016 were utilized to perform a fixed-effects panel analysis. Panel models created predictions for the number of graduates and the number of peer-reviewed publications for programs from grant funding, annual tuition, and number of funded faculty members. In any given program, a 1% increase in annual tuition is associated with 24% more graduates per year, but a single percentage point increase in the mix of NIH grant funding over other funding types is associated with 8% fewer graduates, all else equal. For every 1% increase in annual tuition, a program can expect to have 41% fewer publications per year. Those institutions with higher numbers of graduates tended to have higher numbers of publications. Higher annual program tuition appears to be associated with both higher numbers of physical therapy graduates and lower levels of publications. Different funding sources have variable effects on degree production and scholarly productivity. Data are self-reported by programs on the Annual Accreditation Report, and cause and effect cannot be established through observational design. PubDate: 2019-05-01
Abstract: Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or ‘audience’. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of ‘front-stage’ (observed) versus ‘backstage’ (unobserved) handoffs as distinct performances, tailored to an “audience”. Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence. PubDate: 2019-05-01
Abstract: While person-centred care has gained increasing prominence in recent decades as a goal for healthcare systems, mainstream implementation remains tentative and there is a lack of knowledge about how to develop person-centred care in practice. This study therefore aimed to explore what may be required in order for person-centred care programmes to be successful. The study used an ethnographic method of data collection. This consisted of closely following an implementation programme on a medical emergency ward in a Swedish hospital. Data consisted of participant observation and informal interviews with healthcare providers and their management leaders while they were in the process of training to use person-centred care. These interlocutors were using action learning methods under the guidance of facilitators. Our findings revealed that although the programme resulted in some of the processes that are central for person-centred care being developed, organisational factors and a lack of attention to ethics in the programme counteracted these positive effects. The study highlights the importance of facilitating mechanisms to produce desired results. These include management leaders’ learning about the dynamic and collective nature of learning processes and change. They also include allowing for inter-professional dialogue to enable managers and professionals to reflect deeply on professional boundaries, disciplinary knowledge and power relations in their teams. Teamwork is essential for the development of person-centred care and documentation, in accordance with this specific implementation programme, is also indispensable. The space for inter-professional dialogue should also accommodate their various perspectives on the aims of care and organizational reality. PubDate: 2019-05-01
Abstract: There has been an observed increase in literature concerning feedback within the last decade, with the importance of feedback well documented. Current discourse promotes feedback as an interactive, dialogic process between the learner and the learning partner. While much has been written about effective feedback, less is known about key elements that support dialogic feedback. It is therefore important to investigate what is known about the elements that guide best practice for effective feedback. A scoping review of the extant literature following Arksey and O’Malley’s methodology was conducted. A search of literature published in English identified sixty-one publications eligible for this review. Publications were representative of the international literature from both empirical and non-empirical sources. Feedback elements were extracted from the included publications and categorised into 11 core attributes. The attributes identified feedback as: being a process; criteria-based; requiring multiple forms and sources of data/evidence; needs to be desired by the recipient (i.e. invited and welcomed); timely; responsive to the learner (i.e. tailored to developmental needs/learning preferences of the learner); frequent; future-focussed; reciprocal (i.e. two-way); involves skilful interaction; and is multidimensional (i.e. engages the learner in more than one way). Despite the rhetoric on feedback as a ‘dialogic process’, a gap remains in our understanding around what is required to engage the learner as an equal partner in the feedback process. Further research exploring the impact of specific aspects of the feedback process on practice is required. PubDate: 2019-05-01
Abstract: Educational assessment for the health professions has seen a major attempt to introduce competency based frameworks. As high level policy developments, the changes were intended to improve outcomes by supporting learning and skills development. However, we argue that previous experiences with major innovations in assessment offer an important road map for developing and refining assessment innovations, including careful piloting and analyses of their measurement qualities and impacts. Based on the literature, numerous assessment workshops, personal interactions with potential users, and our 40 years of experience in implementing assessment change, we lament the lack of a coordinated approach to clarify and improve measurement qualities and functionality of competency based assessment (CBA). To address this worrisome situation, we offer two roadmaps to guide CBA’s further development. Initially, reframe and address CBA as a measurement development opportunity. Secondly, using a roadmap adapted from the management literature on sustainable innovation, the medical assessment community needs to initiate an integrated plan to implement CBA as a sustainable innovation within existing educational programs and self-regulatory enterprises. Further examples of down-stream opportunities to refocus CBA at the implementation level within faculties and within the regulatory framework of the profession are offered. In closing, we challenge the broader assessment community in medicine to step forward and own the challenge and opportunities to reframe CBA as an innovation to improve the quality of the clinical educational experience. The goal is to optimize assessment in health education and ultimately improve the public’s health. PubDate: 2019-05-01
Hybrid journal (It can contain Open Access articles)
[2351 journals]
