Teaching and Learning in Medicine最新文献

This study examined the validity of the new MCAT exam (administered since 2015) for predicting medical students' performance on United States Medical Licensing Examinations (USMLE) and compared the findings with those of the prior MCAT version. Participants comprised two samples of students who entered Sidney Kimmel Medical College at Thomas Jefferson University between 2012 and 2020. One sample included 1,111 students (559 men, 552 women) with new MCAT scores who matriculated between 2016 and 2020, and the other comprised 1,312 students (668 men, 644 women) with prior MCAT scores who matriculated between 2012 and 2015. We used students' MCAT scores as predictors of performance on Steps 1, 2, and 3 of the USMLE. Bivariate correlations and path analysis were used for statistical analyses. Path analysis showed new MCAT total scores resulted in R² values of 0.14, 0.11, and 0.16 for predicting performance on Steps 1, 2, and 3 of the USMLE, respectively. The new MCAT total scores demonstrated levels of validity comparable to the prior MCAT for predicting students' performances on the criterion measures. Additional path analyses showed an impact of gender on the predictive validities for some section scores of the new (but not prior) MCAT exam. Replication of this study is recommended in other medical schools to examine generalizability of our findings regarding predictive validities of section scores of the new MCAT exam, particularly regarding gender and section.

Background: Continuity is the organizing principle of the Longitudinal Integrated Clerkship (LIC) and drives its outcomes. In a multispecialty LIC, students are paired with specialty-specific preceptors in each of the core clerkships approximately one half-day per week and work with each of these preceptors longitudinally throughout their clinical training. The general practice (GP) LIC differs in that students are primarily paired with full-scope generalist preceptors who teach the content of several specialties in one setting. It is unknown if assessments from a single preceptor teaching multiple specialties will include sufficient data for summative grading. The aim of this study was to demonstrate non-inferior assessment narrative quality and comparable clerkship clinical grades for students in an urban GPLIC compared to multispecialty LIC students at a United States (U.S.) medical school.

Methods: In 2022, 16 GPLIC preceptors assessed 6 students in pediatrics, obstetrics and gynecology, internal medicine, and family medicine, using forms that allowed assessment in multiple specialties concomitantly. Assessment forms included both comments and ratings of student performance of entrustable professional activities (EPAs) and other skills. Sixteen GPLIC assessment forms were matched to 16 multispecialty forms, deidentified, and evaluated for quality. Adequacy of assessment data was determined by the school's curricular and assessment deans who observed all clerkship grading committee meetings. Feedback on the assessment process was solicited from all 1164 LIC preceptors through an electronic survey at the end of the year.

Results: Overall comment quality did not significantly differ between the groups. There was no significant difference in word count or presence of EPA-specific comments between GPLIC and multispecialty LIC assessment forms. We found no difference in the presence of adequate assessment data between the two groups as judged by final grading committees. The clinical grade distributions of Honors, High Pass, and Pass were not significantly different, and no differences in preceptor feedback about the assessment forms were found.

Conclusion: This study demonstrates that in the inaugural year of an all-LIC curriculum at a US medical school, GPLICs, where preceptors concurrently assess students across multiple specialties, produce noninferior assessment data when compared to multispecialty LIC preceptors. These results suggest the feasibility for parallel GP and multispecialty LICs. This offers medical schools flexibility in expanding clinical training sites beyond traditional specialty-focused academic contexts, while maintaining comparability in assessment.

Evaluation of medical students remains one of the most complex and challenging issues in academic medicine. Evaluation occurs in an educational environment that must cultivate a diverse, collaborative, and resilient physician workforce imbued with skills, drive, and stamina for a lifelong commitment to patient care, self-care, and professional development. Additionally, evaluation must not only be valid and reliable but also relevant to the public who medical students will eventually serve. In U.S. medical education, evaluation, and the assessments on which evaluation is based, has evolved over several centuries. Understanding the history of how, when, and why U.S. medical students have been assessed and subsequently evaluated can inform contemporary dialogue on curricular reform. In exploring this history, several important considerations emerge. First, tiered grading arose through the historical assimilation of U.S. medical schools into universities rather than as a mechanism for assessing clinical competence or acumen. Second, even before influences of university academia suffused medical education, imprudent academic emphasis on the memorization of facts over deeper understanding of, and reflection on, medical sciences and practice was already entrenched. Evaluation systems like tiered grading served to validate-if not accelerate-overreliance on the memorization and recall of scientific facts. As a result, other professional attributes important for medical practice, including intrinsic motivation, group cohesiveness, and diversity of the physician workforce were, and remain, adversely affected. Finally, despite early observations that tiered grading is associated with medical student stress and anxiety, there has been insufficient attention to and mitigation of these effects on medical student wellbeing over the last century. Our collective response to controversies surrounding tiered grading should account for the historical rationality of the adoption of this form of evaluation and its enduring effects on contemporary medical education.

Phenomenon: On the Medical College Admission Test (MCAT), required for entry into all medical schools in the U.S. and many in Canada, average scores are typically lower for individuals from lower socioeconomic status (SES) backgrounds compared to their more advantaged peers, although individuals from every background score in the lower, middle, and upper ranges of the score scale. This achievement gap is potentially due in part to disparities in resource utilization and effective study strategies. Viewing this challenge through a socioecological systems lens can help identify potential systems-level opportunities to support students from these backgrounds to succeed in medicine. Approach: This investigation was the first large-scale review of MCAT preparation strategies, resource utilization, and challenges for examinees from lower-SES backgrounds, focusing on those who obtained higher versus lower MCAT scores. It aimed to examine differences in students' use of evidence-supported learning/studying strategies and challenges experienced in preparing for the MCAT exam. Survey data from the Association of American Medical Colleges Post-MCAT Questionnaire on MCAT preparation strategies and resources used and challenges experienced by 2021-2023 examinees were analyzed, focusing on the 3,240 survey respondents from lower-SES backgrounds. T-tests and chi-square analyses compared continuous variables and proportions between lower- and higher-scoring examinees from lower-SES backgrounds, using Cohen's h to estimate effect size. Findings: Higher-scoring examinees reported greater use of many evidence-supported effective test preparation and learning strategies, including discussing preparation strategies with advisors/peers, establishing baseline capabilities, practicing applying knowledge to practice questions, and evaluating readiness by taking a practice test. Utilization rates of high-value, free/low-cost MCAT resources were significantly higher among top scorers. Conversely, lower-scoring examinees were more likely to report challenges in obtaining reliable internet access, determining how to begin studying, and accessing concrete information about the MCAT exam. Insights: This study highlights critical differences in preparation approaches and challenges among examinees from lower-SES backgrounds. Identifying these gaps may provide insights regarding interventions to improve access to resources and potential improvement to MCAT performance. We provide systems-level ideas for how to better support students from lower-SES backgrounds. For example, learning specialists and advisors could use the findings from this study to screen and educate examinees about evidence-based MCAT preparation strategies and resources. This study identifies opportunities to inform interventions to help students from lower-SES backgrounds advance toward a career in medicine.

As the United States (U.S.) population continues to age, we need to promote a renewed perspective on oral health, helping policy makers understand the impact of poor oral health on older adults with chronic conditions. In this article we describe the issue of lack of oral health education in medical school curricula, the differences in dental school programs, and a brief history of Oral maxillofacial surgery DMD/MD programs in the U.S. In addition to an education focusing on technical skills, dental education should also address scientific, social, and health-related competencies. Not only should the lack of integration of oral health topics in medical curricula be addressed, we should also train future dental professionals on the systemic effects of oral conditions.

Phenomenon: Residents are assumed to be prepared for practice after completing required rotations, but there is little understanding of what clinical conditions they manage. Electronic health records (EHRs) capture resident clinical activities, but few studies have effectively used EHR data to characterize resident experiences. Approach: We extracted EHR data for all patients admitted July 1, 2018 to June 30, 2019 cared for by an internal medicine resident in the Johns Hopkins Hospital residency program. We examined individual residents' encounters with specific clinical conditions, identified using the principal International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10 CM) discharge code and categorized according to the American Board of Internal Medicine (ABIM) Certification Exam Blueprint. We compared numbers and percentages of clinical conditions encountered across individuals and postgraduate years (PGYs). Findings: We included 19,129 admissions for 14,657 patients cared for by 135 residents. ABIM categories most commonly seen were cardiovascular (CV) (mean 20.4%, SD 4.7%), infectious diseases (ID) (mean 19.5%, SD 2.2%), and gastroenterology (GI) (mean 11.2%, SD 3.2%). The largest differences between clinical conditions encountered and ABIM Blueprint were excesses of 10.5% for ID and 6.4% for CV and deficits of 6.1% for rheumatology and orthopedics and 5.5% for endocrinology, diabetes, and metabolism. Total number of admissions per resident ranged 522-963 for PGY-1, 457-1268 for PGY-2, and 224-811 for PGY-3. Percentages of clinical conditions seen varied for individuals in the same postgraduate year: e.g., for CV, ranges were 16-23% for PGY-1, 15-40% for PGY-2, and 10-25% for PGY-3. Insights: Individual residents in the same program had varied inpatient experiences, suggesting a need to understand implications for variation. Linking residents to clinical conditions encountered using EHR data may generate insights that can be incorporated into precision medical education systems to improve learning and clinical outcomes.

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.