Teaching and Learning in Medicine最新文献

Construct: The Knowledge of Malnutrition - Geriatric 2.0' (KoM-G 2.0) instrument was designed to quantify nursing staff malnutrition knowledge in inpatient medical and rehabilitation care facilities, as well as home health care. It has been used to assess grasp of current clinical practice guidelines and proficiency in addressing issues related to malnutrition. It provides insight into familiarity with and capacity to tackle issues pertaining to malnutrition in clinical practice. Furthermore, it has been used assess the effectiveness of educational interventions aimed at improving nursing professionals knowledge and awareness of malnutrition. Background: The quality of nursing education affects malnutrition risk assessment, monitoring of food intake, and effectiveness of nutrition care. Improvements in malnutrition education require determining the current level of knowledge and benchmarking with other countries. In the Czech Republic, no nationwide assessment of nursing staff malnutrition knowledge has ever been conducted. Approach: The purpose of the study was to translate the KoM-G 2.0 instrument, gather initial validity evidence, and evaluate nursing staff knowledge of malnutrition in inpatient medical, rehabilitation care facilities, and home care in the Czech Republic. All inpatient healthcare facilities and home healthcare facilities in the Czech Republic were invited to participate. The Czech version of the internationally standardized KoM-G 2.0 (KoM-G 2.0 CZ) was used to assess nursing staff malnutrition knowledge between 3 February 2021 and 31 May 2021. A total of 728 nurses began the questionnaire, and 465 (63.9%) of respondents completed it and were included in the study. Data analyses examined instrument difficulty, discriminability, and reliability, as well as sources of variation in knowledge scores. Findings: The psychometric characteristics of the KoM-G 2.0 CZ instrument included the difficulty index Q (0.61), the discriminant index (ULI 0.29, RIT 0.38, upper-lower 30% 0.67), and Cronbach alpha (0.619). The overall mean of correct answers was 6.24 (SD 2.8). There was a significant impact of educational attainment and nutrition training on KoM-G 2.0 CZ scores. Conclusions: Our findings provide initial validity evidence that KoM-G 2.0 CZ is useful and appropriate for assessing malnutrition knowledge among Czech nursing staff. Our research identified gaps in knowledge and examples of good practice in understanding malnutrition that can be applied internationally. The knowledge of academic nurses was greater; therefore, we suggest they play a key role in nutritional care. We recommend continuous education to improve understanding of malnutrition in this setting.

Phenomenon: Black women often face more challenges in academic medicine than others and are leaving the profession due to unsupportive work environments, systematic neglect, and experiences of invisibility. Research offers insight into Black women faculty experiences, but studies have largely been conducted on their experiences rather than written by them. We analyzed first-person narratives exploring Black women faculty members' experiences with racial trauma across the academy considering the intersectionality of racism and sexism to lay the foundation for understanding Black women physicians' faculty experiences in similar spaces. Approach: We gathered first-person narratives of Black women faculty members in the U.S. from ERIC, Web of Science, and Ovid Medline. We used a variety of terms to draw out potential experiences with trauma (e.g., microaggressions, stigma, prejudice). Articles were screened by two researchers, with a third resolving conflicts. Drawing on constructs from Black feminist theory, two researchers extracted from each article authors' claims about: (a) their institutions, (b) their experiences in those spaces, and (c) suggestions for change. We then analyzed these data through the lens of racial trauma while also noting the effects of gendered racism. Findings: We identified four key themes from the 46 first-person accounts of racial trauma of Black faculty members in higher education: pressures arising from being "the only" or "one of few"; elimination of value through the "cloak of invisibility" and "unconscious assumptions"; the psychological burden of "walking a tightrope"; and communal responsibility, asking "if not us, then who?" Insights: Black women's narratives are necessary to unearth their specific truths as individuals who experience intersectional oppression because of their marginalized racial and gender identities. This may also assist with better understanding opportunities to dismantle the oppressive structures and practices hindering more diverse, equitable, and inclusive institutional environments where their representation, voice, and experience gives space for them to thrive and not simply survive within the academy, including and not limited to medicine.

Phenomenon: Medical schools must equip future physicians to provide equitable patient care. The best approach, however, is mainly dependent on a medical school's context. Graduating students from our institution have reported feeling ill-equipped to care for patients from "different backgrounds" on the Association of American Medical Colleges' Graduation Questionnaire. We explored how medical students interpret "different patient backgrounds" and what they need to feel prepared to care for diverse patients.

Approach: We conducted an exploratory qualitative case study using focus groups with 11, Year 2 (MS2) and Year 4 (MS4) medical students at our institution. Focus groups were recorded, transcribed, and coded using thematic analysis. We used Bobbie Harro's cycles of socialization and liberation to understand how the entire medical school experience, not solely the curriculum, informs how medical students learn to interact with all patients.

Findings: We organized our findings into four major themes to characterize students' medical education experience when learning to care for patients of different backgrounds: (1) Understandings of different backgrounds (prior to medical school); (2) Admissions process; (3) Curricular socialization; and (4) Co-curricular (or environmental) socialization. We further divided themes 2, 3, and 4 into two subthemes when learning how to care for patients of different backgrounds: (a) the current state and (b) proposed changes. We anticipate that following the proposed changes will help students feel more prepared to care for patients of differing backgrounds.

Insights: Our findings show that preparing medical students to care for diverse patient populations requires a multitude of intentional changes throughout medical students' education. Using Harro's cycles of socialization and liberation as an analytic lens, we identified multiple places throughout medical students' educational experience that are barriers to learning how to care for diverse populations. We propose changes within medical students' education that build upon each other to adequately prepare students to care for patients of diverse backgrounds. Each proposed change culminates into a systemic shift within an academic institution and requires an intentional commitment by administration, faculty, admissions, curriculum, and student affairs.

Evidence: Across all U.S. medical schools, trainees spent a median of 59 hours teaching physical examination skills. Of this time, 30% is dedicated to PPE practice. Despite this prevalence, there are data that show some students find this uncomfortable, especially women. Literature on best practices around PPE highlights voluntary participation, informed consent, and an available alternative to learning physical xamination skills. These are not uniformly available in all learning environments. There are little data around the impact of PPE on students who have experienced or are experiencing sexual trauma. Authors have drawn conclusions about the potential for harm given the prevalence of sexual mistreatment in US higher education.

Implications: Our medical school policy required students to participate in PPE practice, undressing for the exams wearing only shorts (and a sports bra for women) an and a hospital gown. Students who could not participate in this practice for reasons ranging from mobility to religious beliefs had to seek individual formal accommodations to be exempt, putting the onus of change on potentially vulnerable individuals. We evaluated the policy around PPE, and concluded that the school's requirements could be harmful and isolating, as they required students to disclose their personal vulnerabilities while seeking exemptions from being examined by peers. At our institution, a group of students instead advocated for the school to review the policy and create a PPE procedure that was safer and more inclusive while supporting student learning. Our experience emphasized the potential for students to advocate for change, while also highlighting the need for greater research in the field of trauma-informed curricular design for medical education.

Phenomenon: Longitudinal integrated clerkships (LICs) are novel curricula that place medical students in long-term learning and coaching relationships with faculty and require adaptation of teaching practices on the behalf of faculty to maximize learning outcomes. An understanding of how teaching in an LIC model differs from teaching trainees in more traditional models is critical to ensuring curricular innovation success through faculty development. Approach: A qualitative approach was used to describe the teaching practices of faculty and learning experiences of student participants in longitudinal integrated clerkships in different clinical and community settings. Forty-five faculty and 20 students participated in focus groups. Thematic analysis of focus group data was used to identify differences and similarities between groups, sites, and specialties. Findings: Two groupings of themes emerged in thematic analysis: (1) precepting strategies distinctive to the longitudinal integrated clerkship model and (2) precepting strategies enhanced when employed in the LIC model. Distinct to the LIC model, preceptors and students described the importance of understanding the curricular structure and supporting students in longitudinal care of patients. Enhanced in the LIC model are the strategies of relationship-based teaching, support of autonomy, feedback, and support of longitudinal growth in skills. Insights: Students and faculty across LIC sites were broadly aligned in their opinions of best practices for teaching in an LIC model. The longitudinal relationship between student and faculty in an LIC distinguishes this model from traditional block rotations and a distinctive approach to successful teaching is demonstrated. Preceptors use time afforded to build trusting relationships with students, which created opportunity for novel teaching approaches and enhanced otherwise effective teaching strategies. A focus on orientation to the curricular model and support of longitudinal relationships with patients may serve as an anchor for faculty development efforts in the development of an LIC.

Framing the Issue: Medical education programs in the U.S. rely on the aphorism that faculty own the curriculum; that is, the specialized knowledge, skills, and attitudes of a physician are the province of the faculty to be delivered to tuition-paying students. From this view, the learner's role is one of passivity and deference. A contrasting approach, termed curriculum co-creation, frames education as a bi-lateral partnership. Co-creation results from learners, in collaboration with instructors, taking an active role in creating the goals and processes of an educational program. Such a partnership requires substantial revision of the expectations for both learners and instructors. In this Observations article, the idea of co-creation is applied to medical education and an aspirational vision for the role and value of faculty-student co-creation is advocated. Description and Explication: Co-creation partnerships of faculty and students occur in many forms, varying in degree of departure from traditional educational practice. Co-creation principles and partnerships can be deployed for almost all aspects of training including selection and organization of content, effective methods of instruction, and assessment of student learning. The outcomes of co-creation occur at three levels. The most specific outcome of co-creation is characterized by increased student engagement and enhanced learning. Broader outcomes include improved efficacy and value in the educational program and institution while, at the farthest-reaching level, a co-creative process can modify the medical profession itself. Although some specific instructional techniques to promote student involvement and input have historically been deployed in medical education, there is little evidence that students have ever been permitted to share in ownership. Implications for Medical Education: When fully embraced, curricular co-creation will be recognizable through improved student engagement and learning along with a revised understanding of how faculty-student relationships can foment reform in medical education and the culture of the profession. Further scholarship and research will be indispensable to examine how co-creative partnerships can flatten hierarchies within medical education and inspire the medical profession to be more inclusive and effective. Following the model of co-creation is expected to inspire learners by empowering them to participate fully as co-owners of their own education and prepare them to lead medical education in a different direction for the future.

Phenomenon: Despite the nearly universal presence of chief residents within U.S. and Canadian residency programs and their critical importance in graduate medical education, to our knowledge, a comprehensive synthesis of publications about chief residency does not exist. An understanding of the current state of the literature can be helpful to program leadership to make evidence-based improvements to the chief residency and for medical education researchers to recognize and fill gaps in the literature.

Approach: We performed a scoping review of the literature about chief residency. We searched OVID Medline, PsycINFO, ERIC, and Web of Science databases through January 2023 for publications about chief residency. We included publications addressing chief residency in ACGME specialties in the U.S. and Canada and only those using the term "chief resident" to refer to additional responsibilities beyond the typical residency training. We excluded publications using chief residents as a convenience sample. We performed a topic analysis to identify common topics among studies.

Findings: We identified 2,064 publications. We performed title and abstract screening on 1,306 and full text review on 208, resulting in 146 included studies. Roughly half of the publications represented the specialties of Internal Medicine (n = 37, 25.3%) and Psychiatry (n = 30, 20.5%). Topic analysis revealed six major topics: (1) selection of chief residents (2) qualities of chief residents (3) training of chief residents (4) roles of chief residents (5) benefits/challenges of chief residency (6) outcomes after chief residency.

Insights: After reviewing our topic analysis, we identified three key areas warranting increased attention with opportunity for future study: (1) addressing equity and bias in chief resident selection (2) establishment of structured expectations, mentorship, and training of chief residents and (3) increased attention to chief resident experience and career development, including potential downsides of the role.

Problem: A significant proportion of learning during residency takes place through informal channels. Spontaneous collaboration among medical learners significantly contributes to this informal learning and is increasingly recognized as a component of the hidden curriculum in medical education. Yet historically, a disproportionate emphasis in medical education has been placed on didactic, structured, and faculty-initiated methods, leaving an important force in medical education understudied and underutilized. We hypothesize that there is significant educational potential in studying and deploying targeted tools to facilitate collaboration among medical learners. Intervention: At our institution, neurology residents implemented the "Daily Fact Pile" (DFP), a resident-led, email-based collaboration that served as a platform to share clinical pearls in an informal, digital way. Participation was voluntary and participants were encouraged to share facts that were new to them and thought to be clinically relevant. Motivated by the positive collective experience, we conducted a retrospective examination of this phenomenon. In this context, we developed the concept of "mutual microlearning" to characterize this efficient, multidirectional exchange of information. Context: Thirty-six residents in a single neurology residency program utilized the DFP at a large university hospital in the USA between 2018 and 2019. After 21 months of spontaneous and voluntary participation, we assessed the feasibility of the DFP, its impact on the education and morale of neurology residents, and compared its mutual microlearning approach to traditional lectures. This was done through a survey of the DFP participants with a response rate of 80.7%, and analysis of the statistics of participation and interaction with the DFP. Impact: Most participants felt that the DFP was beneficial to their education and thought they often or always learned something new from reading the DFP. The impact of the DFP extended beyond education by improving interest in neurology, morale, and sense of teamwork. The DFP was feasible during neurology residency and participation was high, though participants were more likely to read facts than share them. Lessons learned: Mutual microlearning represents an opportunity to augment residents' education, and well-designed mutual microlearning tools hold promise for complementing traditional teaching methods. We learned that efficiency, ease of use, and a supportive, non-judgmental environment are all essential to the success of such tools. Future research should delve deeper into the underlying mechanisms of mutual microlearning to establish its position within the theoretical frameworks of medical education.

Phenomenon: Ostracism has negative effects on one's fundamental needs. North Americans of Asian ethnicities are at an increased risk of ostracism due to stereotypes labeling them as inherently different to Western cultural norms. We explored Asian Canadian medical trainees' experiences with ostracism during their clinical training. Approach: We conducted semi-structured interviews with 20 medical trainees of Asian ethnicities at 3 Canadian medical schools to explore experiences of ostracism and conducted a thematic analysis guided by the theoretical framework of the temporal need threat model of ostracism. Findings: Participants from East-, South-, and Southeast-Asian sub-ethnic groups completed the study. They voiced experiences of being excluded from clinical and social settings. Ostracism was mainly fueled by systemic racism, power dynamics in medical education, and non-diverse training environments. The model minority myth was a significant contributor to experiences of ostracism. Trainees felt their well-being threatened and many felt resigned to accept ostracism going forward. Insights: Ostracism poses a significant threat to the wellbeing and career progression of Asian Canadian medical trainees. Trainees facing covert ostracism were particularly at risk of entering the resignation stage of hopelessness. This underrecognized problem needs to be addressed by institutions to dismantle harmful stereotypes and prejudiced practices facing these minoritized communities.

Abuse and oppression in medical education persists. Particularly when transitioning to practice, students and residents face dissonance between what they perceive as the ideals of patient care and reality. They witness, and eventually take part in, joking about fellow students and patients, discriminating against minorities, and imposing unbearable workload to subordinates, to mention some practices that have been normalized as the reality of medical training, beyond any possibility of change. We suggest that Critical Pedagogy, an educational movement rooted in Brazil that aims to empower learners and educators as full citizens, can help medical education reinstitute hope for a more humanistic culture by testing new realistic transformative actions, i.e., untested feasibilities, to promote change. We use vignettes based on real situations of oppression to present three concepts of Critical Pedagogy contextualized to medical education: (a) critical consciousness as praxis; (b) pedagogy with learners; and (c) education as a democratic relationship between individuals. The vignettes explore how each one of these concepts can support educators and learners to break chains of injustice and oppression. Perceiving disagreements as opportunities for change, legitimizing the perspectives and values of all engaged in analyzing reality, is needed to nurture critical consciousness. Critical Pedagogy understands education as a partnership of trust between learners and educators and seeks a pedagogy that is built with learners, not on them. Finally, we present suggestions for individual- and systems-level actions that can translate these principles of Critical Pedagogy into a praxis of untested feasibilities for medical education.