Perspectives on Medical Education最新文献

Introduction: In medical education, acts of professional resistance have been studied across all racial and ethnic groups as an antidote to the social harm and injustice festering in medical education. However, not everyone experiences medical education in the same way; some groups experience it quite differently because of their social positions. In particular, Black physicians face anti-Black racism in medical education, which has the potential to shape their resistance in a particular way. This study was designed to understand what professional resistance looks like in Black residents/fellows in North America and how being Black shaped their experiences of resistance.

Methods: This qualitative study used Endarkened storywork to understand how Black GME physicians experienced acts of resistance. Endarkened storywork is a Black-centered approach to research and a way of reclaiming authority to create knowledge. It weaves Endarkened feminism, Afrofuturism, and Indigenous storywork to center storytelling as essential to Black ways of being. We conducted 14 semi-structured interviews and analyzed the data using thematic, theoretical, and emergent coding through the constructs of Re-storying, Endarkened Storywork, and Black quilting.

Results: Black trainees' stories of resistance produced three quilting blocks to illuminate their experiences. First, resistance means continuing to exist in medicine despite all of the profession's efforts to eradicate Black physicians. Second, they work tirelessly to improve Black health and facilitate opportunities for the future of Black people to have a career in medicine. Third, their resistance must contend with a long history of anti-Black racism, which takes a significant toll on the emotional and mental well-being of Black trainees in ways that are best described as racial battle fatigue.

Discussion: For Black trainees, professional resistance is nuanced and calls into the present a long history of anti-Black racism. Their resistance includes occupying space in medicine, securing a future where Black people exist as physicians, and resisting the emotional burden of doing this work. While all forms of professional resistance are worthy of study, researchers should pay particular attention to how it manifests in various racial groups to understand the nuances of different strategies.

Purpose: Integrating diagnostic error and malpractice cases into clinical reasoning education may enhance diagnostic reasoning by highlighting atypical presentations and diagnostic risks in complex contexts. While emotionally engaging, these cases might also affect information retention. This study examines how malpractice, error, and neutral case presentations influence recall for different information types and their interaction with learners' interest, satisfaction and anxiety levels.

Methods: In this two-phase between-subjects experiment, 89 first-year general practice (GP) residents reviewed four clinical vignettes in either malpractice, diagnostic error, or neutral formats. Vignettes were structurally identical, with claim-related details in malpractice versions replaced by general medical information in others. Anxiety was measured pre- and post-exercise. After a one-hour filler task, participants completed a free recall task, and their interest and satisfaction levels were assessed. Recalled idea units (clinical case-specific, medical-theoretical, claim-specific) were analyzed using ANOVAs.

Results: Anxiety, interest, and satisfaction levels remained similar across conditions. The proportion of total recalled idea units did not differ significantly (malpractice 11.38%, neutral 12.91%, error 13.12% p = 0.57). However, malpractice participants recalled fewer clinical case-specific units (malpractice 12.19%, neutral 19.43%, error 15.87% p = 0.007) while recalling more claim-specific units compared to medical-theoretical units in the other conditions (malpractice 7.23%, neutral 0.42%, error 1.3% p < 0.001).

Conclusion: GP residents retained fewer clinical case-specific details from malpractice claim vignettes than from neutral vignettes, with the missing information substituted by claim-specific details, without an increase in anxiety or interest. Further research is needed to understand the long-term impact of these differences on future diagnostic accuracy in clinical practice.

Introduction: Surgical simulation training substituting a live animal for a human patient is a continuing practice. Despite clear ethical controversy, many perceive this type of simulation to be 'high fidelity' and therefore valuable. This study employs a sociomaterial perspective to explore how use of a live animal mediates learning activity and behaviour during a trauma surgical simulation course.

Methods: This international, focused ethnography generated data through observation of surgical simulation courses in six different countries. A narrative analysis was conducted using instrument-mediated learning theory as a lens for interpretation.

Results: The key finding is the dual and fluid existence of a live animal as an instrument for learning, variably perceived as a simulator tool for training and as a patient that must be saved. When framed as a tool, surgical knowledge and skills are practiced with learning acquired via epistemic and pragmatic mediation. Performing a thoracotomy denotes a critical moment; procedural unfamiliarity, evident haemorrhage and inherent risk of a deadly outcome contribute to uncertainty and clinical complexity. Learners are hence more likely to frame the animal as a patient. This experience has psychological fidelity, feeling more authentic as actions have consequences. Risk of failure to sustain the life of the animal mediates reflexive learning, teaching the learners about themselves and their abilities.

Conclusion: Live animal simulation training mediates surgical learning differently, dependent on whether the animal is framed as an instrument or as a patient. The animal's ability to bleed and exsanguinate to death creates risk and uncertainty as learners perform complex skills under pressure of significant consequence. Authenticity could be amplified if the animal is framed as a patient throughout the simulated learning event.

Background & need for innovation: In contemporary medical education, there remains a notable gap in effectively addressing the complex societal and cultural dimensions of healthcare, particularly regarding the LGBTQIA+ community. Medical students often receive limited exposure to the nuanced aspects of gender and sexual diversity, which is crucial for fostering an inclusive healthcare environment.

Goal of innovation: This study aimed to bridge this gap by integrating queer museum arts into the undergraduate medical curriculum to promote reflective engagement and dismantling of biases among future healthcare professionals.

Steps taken for development and implementation of innovation: In this mixed-method study 24 randomly selected final-year medical students underwent a four-week flipped-classroom program divided into three phases: an "Orientation phase" to train students in Visual Thinking Strategies (VTS); an "Exploration" phase, where students engaged with queer arts in small groups to identify and discuss discrimination and bias through a pessimistic lens; and a "Reinforcement" phase, which encouraged reflection on inclusive practices in healthcare through an optimistic perspective. Students were instructed to write a narrative report from a queer perspective in the first phase and a physician perspective in the second phase.

Evaluation of innovation: Students' confidence before and after the program were collected and one-on-one semi-structured interviews were conducted. Then, a sequential analysis was performed, using quantitative results to drive qualitative analyses to explore student experiences and evaluate program effectiveness. Engagement with queer arts facilitated deeper emotional and intellectual connections, leading to a transformative shift in perceptions and attitudes towards inclusivity in healthcare. Participants initially exhibited low confidence levels in areas such as gender diversity, gender inequality related discussion, understanding multiple perspectives etc., largely due to fear of judgment, societal stigma, and a lack of prior exposure. However, by the end of the program, significant improvements were observed, with higher confidence across many areas driven by critical reflection and deeper engagement with gender and sexual diversity.

Critical reflection on your process: The program served as a catalyst for challenging students to confront their biases through disorienting dilemmas and engage in critical reflection. This deep, internal shift not only broadened their understanding of gender and sexual diversity but also redefined their roles as advocates for inclusivity in healthcare. Program evaluation demonstrated its effectiveness in enhancing awareness, confidence, and equipping future medical professionals with the mindset necessary to create inclusive and compassionate care environments.

Caring for patients in the outpatient setting is a significant part of many physicians' responsibilities due to healthcare's shift from inpatient to outpatient settings. Outpatient care is complex and characterized by longitudinal relationships among all who work in this setting, including the patients. There is recognition of the need to enhance graduate medical education specifically situated in the outpatient setting. Considering that good educational practices need to be grounded in theoretical principles, the aim of this conceptual article is to analyze and explain learning in the outpatient care setting through a critical appraisal of selected learning theories. Four theories were selected to explore residents' learning in relation to characteristics of the outpatient setting: 1) Cultural-Historical Activity Theory, 2) Situated Learning Theory, 3) Cognitive Development Theory and 4) Self-regulated Learning Theory. These theories were selected for their socio-cultural perspective or their focus on the learner. We highlight the implications for medical education and how these learning theories can inform teaching and learning in the outpatient care setting. For example, identification of contradictions and tensions between educational activity systems can promote expansive and transformational learning. By recognizing the unique opportunities for learning in the outpatient setting and applying learning theories, program directors and education specialists can develop better training programs resulting in more competent physicians to care and serve the needs of patients and society.

Introduction: Professionalism, influenced by regional context and societal values, is essential in doctor-patient relationships, patient experiences, and clinical outcomes. However, formal education alone fails to cultivate professionalism effectively. Research highlights the hidden curriculum's detrimental impact on medical students' professionalism. Nonetheless, strategies to teach professionalism in specific curriculum areas and to counteract hidden curricula, particularly for clinical clerkships, remain underexplored. This study evaluates a structured, student-led professionalism training program in a clerkship.

Methods: Over one year, we implemented and replicated an educational intervention on professionalism in four emergency medicine clerkship groups. Grounded in constructivist and transformative learning theories, the intervention aimed to enhance students' reflective capacities by addressing the hidden curriculum. It included briefing sessions on professionalism models and student-led discussions on clinical cases encountered to uncover implicit lessons. Students' understanding was reinforced through anonymous self- and peer assessments of professionalism traits. The impact was evaluated qualitatively through inductive thematic analysis of student reflections and quantitatively through student feedback based on the Kirkpatrick model.

Results: The training received highly positive evaluations from students. Quantitative analysis showed significant score increases in knowledge and ability (using the Wilcoxon Signed Rank Test). Students demonstrated the ability to reflect on the hidden curriculum and highlighted three key themes: professional attributes, sociocultural context, and system-level factors. Subthemes included communication, empathy, learning commitment, cultural competence, hierarchy, and family engagement.

Discussion: This study presents a practical clerkship professionalism training model demonstrating that regular case-based discussions and anonymous self- and peer assessments help students identify and reflect on professional behaviors within the hidden curriculum.

Background and need for innovation: There is a large body of evidence that assessment systems in medical education are inequitable for many groups of learners. A common approach to improve equity has been the use of organizational strategies, where training program leaders work to develop and implement improvements in existing assessment systems from their perspective to improve equity. However, emerging assessment approaches, such as justice-oriented assessment, argue that assessment systems must be made more equitable by critique and re-building through co-design with learners, assessors, and other key users. Little is known about how to apply these methods to workplace-based assessment in medical education.

Goal of innovation: To fill the knowledge gap about how to co-design a more equitable, justice-oriented, workplace-based assessment system in pediatric post-graduate medical education.

Steps taken for development and implementation of innovation: Using the Design Justice framework, the authors completed 4 of the 5 phases of Design Thinking to co-design with learners and other users a workplace-based assessment system in their institution's pediatric residency program.

Evaluation of innovation: To understand whether and how Design Justice principles were present and operationalized in the process of co-designing the assessment system, the authors evaluated the design activities in each phase of the Design Thinking process, the outputs of the design process, and the experiences of participating users.

Critical reflection: Evidence of Design Justice principles included participants' feelings of being heard, affirmed, and empowered, as well as the design teams' iterative, critical reflection on making the project accessible, accountable, sustainable, and collaborative. This project offers a practical example of co-designing a justice-oriented assessment system, the process and principles of which can inform the efforts of advancing equity in assessment.

Introduction: Co-creation is gaining momentum in health professions education with positive effects on learners' engagement and motivation. Concurrently, emotional challenges faced by learners-such as stress, anxiety, burnout, and depression-continue to be a problem for health professions education leaders. This review seeks to explore how learners' active participation in shaping their educational experience may influence their well-being.

Methods: We searched MEDLINE, Scopus, Web of Science, and CINHAL. We included studies conducted within a health professions education context, which involved learners in curriculum design processes, and reported outcomes related to learners' well-being. We used Seligman's PERMA model to report these terms.

Results: Of 4222 reviewed articles, 24 met the inclusion criteria. All studies reported outcomes related to learners' well-being across the five domains of the PERMA model: Positive Emotions (n = 23), Meaning (n = 20), Positive Relationships (n = 10), Engagement (n = 4), and Accomplishment (n = 4). Studies describing a true student-staff partnership approach (n = 17) involved smaller learner groups, focused on developing new curricula reported outcomes related to learners' positive well-being in all five domains. Studies describing pseudo-partnership (N = 7) also reported positive learner well-being, but not in all domains, and mostly focused in the context of developing extracurricular mental health initiatives.

Conclusions: Co-creation, especially when true student-staff partnership is used, can have a positive influence on learners' well-being. This underscores the importance of empowering learners to participate in shaping their education. Lessons learned from this review may encourage curriculum planners and education leaders to create opportunities and initiatives for involving learners in the design of their education.

Introduction: For future doctors, learning compassion skills is heavily dependent on female and male faculty's role modelling in practice. As such, more insight into the relationships between faculty's compassionate behavior, faculty gender and role modelling is needed.

Methods: In this cross-sectional survey, we analyzed 12416 resident evaluations of 2399 faculty members across 22 Dutch hospitals. The predictor variables were: observed compassionate behavior, faculty gender (reference category: female), and an interaction term between those two. Our outcome variables were: person, teacher and physician role model. All variables, except for faculty gender, were scored on a 7-point Likert scale ranging from 1 "totally disagree" to 7 "totally agree".

Results: Female faculty scored slightly but significantly higher (M = 6.2, SD = 0.7) than male faculty (M = 5.9, SD = 0.6) on observed compassionate behavior. Observed compassionate behavior was significantly positively associated with being seen as a role model teacher (b = 0.695; 95% CI = 0.623 - 0.767), physician (b = 0.657; 95% CI = 0.598 - 0.716) and person (b = 0.714; 95% CI = 0.653 - 0.775). Male gender showed significant negative associations with role model teacher (b = -0.847; 95% CI = -1.431 - -0.262), physician (b = -0.630, 95% CI = -1.111 - -0.149) and person (b = -0.601, 95% CI = -1.099 - -0.103). The interaction term showed positive significant associations with role model teacher (b = 0.157, 95% CI = 0.061 - 0.767), physician (b = 0.116, 95% CI = 0.037 - 0.194) and person (b = 0.102, 95% CI = 0.021 - 0.183).

Discussion: Dutch residents, in general, observed their faculty to be compassionate towards patients and families and faculty's observed compassionate behavior is related to being seen as a role model. However, male faculty benefit more from demonstrating compassion, as it has a greater positive influence on their perceived role model status compared to female faculty.

Introduction: Self-censorship and self-disclosure are two ways students negotiate and reconcile their personal identities with their burgeoning professional identities in order to succeed in the clinical learning environment. In this study, the authors explored how clinical medical students with minoritized identities navigate self-censorship and self-disclosure. Overall, the authors sought to better characterize perceived educational safety among minoritized medical students and identify strategies to better support trainees from diverse backgrounds.

Methods: The authors utilized constructivist grounded theory methodology and conducted individual qualitative interviews from 2022-2024 with 16 clinical medical students in the United States who held one or more minoritized identities.

Results: Participants viewed censorship as a mechanism for self-preservation in the context of biased and hierarchical learning environments, while disclosure served as a tool for connection and practicing authenticity. Navigating censorship and disclosure while holding the weight of minoritized identities proved challenging and affected learning. However, perceiving safety, trust, and invitation from others could facilitate this process. While participants noted the power of disclosure in improving patient care, many found it difficult to engage in disclosure while maintaining professional boundaries. Despite these challenges, participants found ways to use both censorship and disclosure to assert their identities and reclaim power in their identity narratives.

Conclusions: Exploring self-censorship and self-disclosure provides valuable insight into perceived educational safety among students with minoritized identities. It is important for educators to be mindful of self-censorship and co-construct opportunities for disclosure with learners in order to promote inclusivity and equity within the clinical learning environment.