Perspectives on Medical Education最新文献

Introduction: In medical education, assessments have high-stakes implications. Yet, assessments are rife with unconscious bias, which contributes to inequitable social structures. Implicit bias in assessment must be addressed because medical educators use assessments to guide learning and promote development of physicians' careers. In this scoping review, the authors map the literature on implicit bias in assessment, as it applies to: 1) the types of implicit bias addressed, 2) the targets and types of interventions studied or proposed, and 3) how publications describe intervention efficacy.

Methods: The authors conducted a scoping review of the literature on interventions to mitigate implicit bias that was published between January 2010 and August 2023. Author pairs independently screened articles for inclusion and extracted data. Discrepancies were resolved with discussion and consensus. Qualitative and quantitative analysis was informed by Anderson et al's three assessment orientations: fairness, assessment for inclusion (AfI), and justice.

Results: 7,831 articles were identified; 54 articles were included. The majority (n = 37; 69%) of articles focus on implicit bias toward those underrepresented in medicine. Interventions to mitigate implicit bias were targeted toward admissions and applications, faculty training, recruitment, summative assessments, and evaluation templates. Interventions had fairness (n = 43; 96%) and AfI (n = 22; 49%) orientations; no articles used a justice-orientation. For the sub-set of research studies (n = 40), almost all (n = 34; 85%) examined a single program/institution.

Discussion: This scoping review showed that more work is necessary to address different types of implicit biases, move scholarship beyond single-institution studies, refine existing interventions, and evaluate how efficacy is defined.

Background: Advocacy and resistance are undertheorized in medical education, yet trainees are often encouraged by their teachers to engage in these activities as a way of helping patients, mitigating healthcare system weaknesses, or challenging harms or injustices. How health professionals can and should engage in advocacy or resistance (which can be treated as a dyad of advocacy-resistance) is undertheorized, which can create confusion for trainees and lead to harms. Although acts of advocacy-resistance are often framed as pro-social, applications of advocacy-resistance can create inequity in seeking to reduce it, and they can create challenges for those trying to negotiate this perilous landscape.

Method: The authors respond to the need for a more robust theoretical grounding in this space by taking a dialogical approach (based on abductive group discussion and debate, reading and rereading the literature, and collaborative writing and theory building) to explore ethical dilemmas that can arise from healthcare practitioner and trainee engagement in acts of advocacy-resistance.

Findings: Four broad dilemmas arising from healthcare practitioner and trainee acts of advocacy-resistance are described: where the loci of responsibilities lie, how professional identity and agency are situated within a collective, balancing competing needs and priorities, and managing harm that can result from engaging in advocacy-resistance. The authors describe contributing factors including equity, identity, needs, priorities, responsibilities, and the advocacy-resistance dyad itself.

Conclusions: In better understanding the dilemmas that acts of advocacy-resistance can create, healthcare providers, educators, and trainees should be better able to negotiate this complex and yet necessary space.

Introduction: Developing communication skills is essential for medical students to work in modern medical practice. A collaborative learning environment, such as Team-Based Learning (TBL), is a promising environment for developing communication skills. In this study, we investigated 1) how medical students self-report their communication skills in a TBL environment and 2) to what extent students perceive a TBL environment as contributing to their communication skills development.

Method: We conducted a quantitative study with a qualitative element involving Brazilian undergraduate medical students from one Medical School. Participants completed the Interpersonal Communication Competence Scale and the Team-Based Learning Environment Scale, including an open-ended question. We used ANOVA to compare responses across the seven semesters and thematic analysis for the open-ended responses.

Results: Of the 416 students invited, 307 (74%) responded to both scales. Students had high scores on communication skills. Students highly valued the contribution of five domains of the TBL learning environment: teachers' decisions, teachers' attitudes, students' characteristics, team characteristics, and contextual factors. The sixth domain, formative assessment, was highly valued by first-year students with a downward trend across semesters. Key factors contributing to communication skills development were teachers' alignment with the educational methodology and students' attitudes within teams. Additionally, students noted that their perception of safety and trust to provide feedback influenced their communication skills development.

Conclusion: These findings suggest that a TBL environment can maintain students' communication skills. Various elements of the TBL environment play a role here, particularly teachers' alignment, students' attitudes, and a supportive classroom atmosphere.

Introduction: Advanced training experiences are required in certain countries for subspecialization. In the United States, a decline in Milestones and in levels of supervision for Entrustable Professional Activities for incoming subspecialty fellows has been described and attributed to changes in context that fellows experience. We aimed to explore this transition to advanced training, and specifically to describe which contextual factors are salient to fellows at the residency to fellowship transition and the supports available for a smooth transition to fellowship.

Methods: Using contextual competence as a sensitizing concept, ten semi-structured interviews with first- and second-year pediatric subspecialty fellows from three subspecialties were performed at a large academic medical center in 2023, using thematic analysis informed by elements of constructivist grounded theory.

Results: Contextual factors that impacted the transition included changes in systems, necessary knowledge, and roles and responsibilities. At times, participants describe a tension between feeling like novices while simultaneously feeling like they should have more expertise than they had. Supports in navigating this tension, and in navigating the transition more generally, included formal orientations, fellow behaviors and perspective, and input from others.

Conclusions: The transition to advanced training is characterized, at times, by experiencing tension between feeling like a novice while feeling like one should have expertise, with fellows' own behaviors and the support of those around them being essential to fellows' smooth transition. While fellowship programs offer orientations, systems-level solutions for supporting fellows' navigation of the transition are underexplored.

Introduction: The transition from medical school to residency, especially during the postgraduate year (PGY) internship, poses unique challenges as graduates navigate clinical practice complexities. Understanding PGYs' experiences is crucial for developing effective support strategies to promote their professional growth and well-being.

Methods: This qualitative, longitudinal study followed ten PGYs from August 2021 to July 2023, using biannual audio diary based on open-ended questions to capture their experiences. Data analysis, guided by Activity Theory, focused on role conflicts and contradictions as PGYs transitioned from learners to practicing physicians.

Results: The analysis revealed prevalent role conflicts and contradictions, primarily due to the tension between the PGYs' roles as learner and healthcare provider. Differences in objectives between PGYs and practicing doctors further exacerbated these conflicts, leading to clashes in priorities and care approaches. Consequently, PGYs experienced reality shock, lack of confidence, and feelings of incompetence, compounded by heavy workloads and exhaustion. These findings underscored the need for support and resources to help PGYs navigate these challenges and succeed in their healthcare roles.

Discussions: Using Activity Theory to analyze the inherent challenges and contradictions within the PGY experience, this study offers insights for enhancing PGY preparedness, fostering both professional development and well-being. Drawing on recommendations supported by existing literature, which are stratified by tools, rules, and division of labor, we propose targeted strategies to address specific facets of the PGY role, thereby improving the overall training environment. This research highlights the need for tailored interventions to support PGYs through the challenging transition into clinical practice.

Introduction: Traditionally, clinical education has combined classroom theory with hospital-based practical experiences. Over the past 50 years, simulation-based training, particularly virtual reality (VR), has gained prominence for its flexibility and scalability. This article describes the development, implementation and evaluation of a VR-based brain death diagnostic training module at the University of Münster over a three-year period.

Methods: A multidisciplinary team developed the VR scenario to simulate a realistic intensive care unit, in line with German guidelines for brain death diagnosis. The module includes a tutorial and a preparatory video podcast to accommodate varying levels of VR experience. The course maintained its former small-group format, integrating VR to replace a manikin-based brain death examination. A randomized pilot study compared the traditional and VR-based approaches.

Results: Feedback from over 800 students indicated a strong preference for VR training, with a significant increase in perceived competence in brain death diagnosis. The VR module also increased the individual training time and provided more varied clinical scenarios than traditional methods. Continuous feedback led to iterative improvements, including reflex simulations and improved hardware management.

Discussion: The VR-based training was well received, demonstrating its potential to revolutionize medical education by providing immersive, realistic simulations. Challenges such as initial hardware adaptation and high personnel costs were addressed through comprehensive tutorials and structural adjustments. The success of this module has led to the development of additional VR courses, optimizing the use of hardware and justifying the initial investment.

Conclusion: The integration of VR into medical education at the University of Münster has proven effective, enhancing student engagement and competence in brain death diagnosis. The positive outcomes suggest a promising future for VR in medical education, highlighting the importance of innovative tools in the preparation of future medical professionals. Efforts are continuing to broaden the application and accessibility of VR-based training.

Background: Educators struggle to implement Interprofessional Education (IPE) in workplace settings. We adopted an educational design research (EDR) approach to implement an IPE activity and establish design principles supporting IPE implementation in workplace settings.

Method: We adopted an iterative process of analysis/exploration, design/construction and evaluation/reflection. We performed a scoping review, visited examples of IPE initiatives and involved workplace professionals to define preliminary design principles for implementation. An IPE activity was implemented where students from nursing, midwifery and medicine care for patients together. Continuous reflection during the EDR process supported the refinement of design principles.

Results: We describe 14 design principles for implementation of IPE: (1) Set an objective; (2) Make the project evidence informed and theory driven; (3) Nurture a growth mindset; (4) Stimulate transformative participation; (5) Be aware of culture; (6) Support faculty members; (7) Align learning outcomes (8) Design formative and reflective assessment methods; (9) Position within an authentic context; (10) Facilitate informal interaction; (11) Balance patients' safety with attributing responsibility; (12) Align with the workplace, seize opportunities to improve interprofessional collaboration; (13) Evaluate the implementation; AND (14) Trust the process. The design principles related to three overarching concerns describing IPE implementation as a change process: patient safety, workflow and culture.

Discussion: The 14 design principles support context sensitive IPE implementation in the workplace. The EDR approach nurtured transformative participation, empowering stakeholders to participate and contribute to design and decision making. This resulted in an evidence informed, interprofessional cocreation process in and with the workplace that was aligned with existing workflow and organizational culture.

Purpose: Medical school admissions is a vital area for advancing diversity, equity, and inclusion (DEI). Integrating bias recognition and management (BRM) within the context of admissions is critical in advancing DEI. However, there is a dearth of empirically informed literature on BRM in the admissions context. Therefore, this study sought to explore how individuals involved in admissions decisions process and integrate bias related feedback.

Methods: The authors conducted a qualitative exploratory study using constructivist grounded theory. 21 semi-structured interviews were conducted with various participants in the admissions process at a North American medical school who had participated in bias related training. Participants included medical school faculty, senior medical students, and community volunteers.

Results: Overall, participants expressed diverse perspectives on their personal biases and how these biases impact admissions decisions. Their reflections were shaped by their identities, values, and priorities, which varied based on whether they were faculty members, students, or community members. Participants also highlighted that their biases influenced their perceptions of the ideal admissions candidate, thus influencing their decision-making process. They emphasized the need for more opportunities to engage in dialogue with peers to openly share and discuss how to recognize and manage their biases.

Conclusion: Our study suggests that fostering critical reflection about identity tensions, building and sustaining a community of practice, and facilitating sustained dialogue may provide admissions committees with an evidence-informed, meaningful, and sustained approach to advancing DEI through bias recognition and management.

Introduction: Feedback literacy (FBL) is a critical skill for learners encompassing four behaviors: appreciating feedback, making judgements, managing affect, and taking action. Little guidance has been available for clinical preceptors to promote FBL. The R2C2 feedback and coaching model that guides teachers through building Relationships, exploring Reactions and Reflections, discussing Content and Coaching to co-develop an action plan for follow-up may support FBL. This study sought to identify whether R2C2 conversations operationalized FBL behaviors and the factors that appeared to influence FBL.

Methods: Based on data from a multi-institutional, qualitative study involving 15 dyads of learners (residents and medical students) and their physician preceptors, a secondary analysis of R2C2-guided feedback conversations and debriefing interviews was undertaken. A framework analysis mapped the data to FBL behaviors and explored factors that impacted behaviors in the context of the research and theories underpinning R2C2 and FBL.

Results: Most elements of FBL behaviors were demonstrated in R2C2 conversations. Appreciating feedback and making judgements were most consistently noted. There was less evidence of managing affect as learners indicated acceptance of feedback. There was variability in the co-creation of action plans. Some created action plans, others had incomplete or no plan for immediate action or follow-up. FBL appeared to be impacted by learner-preceptor relationships, active learner engagement in feedback discussions, and personal characteristics.

Discussion: Our analysis demonstrated that effective use of the R2C2 model could enhance FBL behaviors provided attention was paid to optimizing all phases of R2C2, particularly co-creation of action plans for follow-up.

In this introduction, the guest editors of the "Next Era in Assessment" special collection frame the invited papers by envisioning a next era in assessment of medical education, based on ideas developed during a summit that convened professional and educational leaders and scholars. The authors posit that the next era of assessment will focus unambiguously on serving patients and the health of society, reflect its sociocultural context, and support learners' longitudinal growth and development. As such, assessment will be characterized as transformational, development-oriented and socially accountable. The authors introduce the papers in this special collection, which represent elements of a roadmap towards the next era in assessment by exploring several foundational considerations that will make the next era successful. These include the equally important issues of (1) focusing on accountability, trust and power in assessment, (2) addressing implementation and contextualization of assessment systems, (3) optimizing the use of technology in assessment, (4) establishing infrastructure for data sharing and data storage, (5) developing a vocabulary around emerging sources of assessment data, and (6) reconceptualizing validity around patient care and learner equity. Attending to these priority areas will help leaders create authentic assessment systems that are responsive to learners' and society's needs, while reaping the full promise of competency-based medical education (CBME) as well as emerging data science and artificial intelligence technologies.