Teaching and Learning in Medicine最新文献

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.

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: 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.

Issue: Across the United States, the majority of medical schools teach physical examination using some form of peer physical examination (PPE). The process of being physically exposed in the presence of colleagues can be uncomfortable and cause students distress for myriad reasons ranging from religious and cultural practices to body dysmorphia and previous trauma experiences. This is especially problematic in educational systems which offer no other options, or make PPE a requirement of the curriculum.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: 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.

Phenomenon: Residents interact with their peers and supervisors to ask for advice in response to complicated situations occurring during patient care. To provide a deeper understanding of workplace learning, this study explores the structure and dynamics of advice-seeking networks in two residency programs. Approach: We conducted a survey-based social network study. To develop the survey, we conducted focus group discussions and identified three main categories of advice: factual knowledge, clinical reasoning, and procedural skills. We invited a total of 49 emergency medicine and psychiatry residents who had completed at least six months of their training, to nominate their supervisors and peer residents, as their sources of advice, from a roster. Participants identified the number of occasions during the previous month that they turned to each person to seek advice regarding the three broad categories. We calculated the density, centrality, and reciprocity measures for each advice category at each department. Findings: The response rates were 100% (n = 21) and 85.7% (n = 24) in the emergency medicine and psychiatry departments, respectively. The advice network of emergency medicine residents was denser, less hierarchical, and less reciprocated compared to the psychiatry residents' network. In both departments, PGY-1s were the top advice-seekers, who turned to PGY-2s, PGY-3s, and supervisors for advice. The "procedural skills" network had the lowest density in both departments. There was less overlap in the sources of advice for different advice types in the psychiatry department, implying more selectivity of sources. Insights: Complex social structures and dynamics among residents vary by discipline and level of seniority. Program directors can develop tailored educational interventions informed by their departments' specific network patterns to promote a timely and effective advice-seeking culture which in turn, could lead to optimally informed patient care.

Phenomenon: Balancing the demands of medical training and parenthood is challenging. We explored perceptions of programmatic support, parental leave, breastfeeding, and self-reported biggest challenges among a large cohort of physician mothers in a variety of medical specialties and across the stage of training when they had their first child. Our goal was to inform strategies to help improve the physician parent experience. Approach: This cross-sectional, observational survey study was performed using a convenience sample from an online physician-mom support group from January to February 2018. Descriptive statistics and bivariate analyses were used to report results and examine relationships between career stage at first child and outcome variables. Responses to the open-ended question, "What is your biggest challenge as a physician mom?" were qualitatively analyzed. Findings: The survey received 896 complete responses. The most common specialties were obstetrics and gynecology (25.3%), pediatrics (19.9%), internal medicine or medicine/pediatrics (17.1%), and family medicine (10.2%). The majority of participants (63.9%) had their first child during medical training, including medical school (14.3%), residency (35.8%) or fellowship (13.6%). Medical students were less likely to perceive programmatic support than residents or fellows (44.1% vs. 63.1% vs. 62.3%, respectively), and only 19.9% of participants who became parents during medical training reported having a clear and adequate parental leave policy. Nearly 70% of participants breastfed for six months or more, with no statistical differences across career stage. Most participants (57.6%) delayed child-bearing for one or more reasons, with 32.3% delaying to complete training. The most common codes applied to responses for 'biggest challenges as a physician mom' were insufficient time, lack of work-life balance, missing out, and over-expectation. Insights: Physician mothers, particularly those who had their first child during training, continue to struggle with support from training programs, finding work-life balance, and feelings of inadequacy. Interventions such as clear and adequate leave policies, program-sponsored or onsite childcare and improved programmatic support of breastfeeding and pumping may help to ameliorate the challenges described by our participants.

Phenomenon: Tertiary education in post-apartheid South Africa has faced many challenges regarding class, language, and race. Even though previously white Afrikaans-rooted universities now have a diverse student population, recent student protests have highlighted the ongoing need for decolonization in higher education. In addition, the majority of public hospitals in the country function under significant staffing, infrastructure, and equipment shortages. Although the mistreatment of medical students has been well described internationally, to date no South African data exists. The aim of this study was to identify experiences of mistreatment of medical students by clinicians and academics at a South African university and to describe the type of mistreatment experienced, the perceived mental health effects, and the influence on academic performance, resilience, and students' knowledge of current reporting systems. Approach: A cross-sectional study was conducted through a locally developed online survey of 443 medical students at a South African university in May to June 2018, comprising of both open and closed ended questions. Levels of psychological distress (K10) and resilience (CD-RISC -10) were measured. Chi-square and student t-tests were used for the analysis of associations, and linear regressions were used to assess predictors of psychological distress. Qualitative data were analyzed thematically using the approach described by Braun and Clarke. Findings: Of 800 eligible medical students at Stellenbosch University, 443 students (55.4%) completed the survey. Mistreatment, comprising of being ignored/excluded (83.4%), offensive gestures (75.0%), verbal abuse (65.1%) and discrimination (64.4%), was prevalent and pervasive, and was perpetrated mainly by registrars (46.7%) and other medical staff (43.8%). Mistreatment was associated with psychological distress, which was generally high and more severe for females. Resilience, which was higher for males, moderated the effects of gender and perpetrator type on distress. Only 15% of students who had experienced mistreatment, either directly or indirectly, reported it, of which more than half (52.8%) were not happy with the outcome. Most students (80.9%) were not aware of the systems in place to report mistreatment. Insights: Student mistreatment is more highly prevalent among medical students at a South African university compared with studies conducted internationally. Despite over 20 years of democracy in South Africa, high rates of racial and gender discrimination were reported and descriptions of racial, language and gender discrimination were particularly concerning. Since the findings of this study, an anti-bullying poster-campaign has been initiated at the university as well as an online reporting system.

Issue: Efforts to improve medical education often focus on optimizing technical aspects of teaching and learning. However, without considering the connection between the pedagogical-curricular and the foundational philosophically-defined educational aims of medicine and medical education, critical system reform is unlikely. The transformation of medical education requires leaders uniquely prepared to view medicine and medical education critically as it is and as it ought to be, and who have the capacity to lead changes aimed at overcoming the identified gaps. This paper proposes a five-level topology to guide leaders to develop this capacity. Evidence: Without reference to a shared understanding of a larger, more profound philosophical vision of the ideal physician and of the educational process of "becoming" that physician, efforts to change medical education are likely to be incremental and insufficient rather than transformative. Such efforts may lead to frequent pedagogical-curricular reforms, shifting evaluation models, and paradigmatic conflicts in medical education systems across contexts. This paper describes a leadership program meant to develop transformational educational leaders. The leadership program is built on and teaches the five-level topology we describe here. The five levels are 1) Philosophy 2) Philosophy of Education 3) Theory of Practice 4) Implementation and 5) Evaluation. Implications: The leadership development program exemplifies how the topology can be implemented as a framework to foster transformation in medical education. The topology is a metaphor exemplified by the Mobius Strip, a continuous and never-broken object, which reflects the ways in which the five levels are inherently connected and reflect on each other. Medical education leadership requires deeper engagement with paradigmatic thought to transform the field for the future.

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.