Teaching and Learning in Medicine最新文献

Phenomenon: Choosing a medical specialty is a critical decision that significantly impacts medical students' future career. Understanding the factors influencing this decision-making process is important for medical educators, policymakers, and healthcare providers to develop effective strategies that support and guide students in making informed decisions. Approach: We distributed an online self-administered questionnaire to clinical-year medical students (Years 4 to 6) and interns from all medical faculties in Jordan. The questionnaire gathered demographic information, specialty preferences, and factors influencing specialty decision-making. We analyzed the data using descriptive statistics and logistic regression. Findings: 1805 participants completed the questionnaire (51.7% women). General surgery was the most preferred specialty among both genders, followed by internal medicine. Women significantly preferred family medicine, pediatrics, obstetrics and gynecology, and dermatology, whereas men significantly preferred urology, orthopedic surgery, neurosurgery, general surgery, and internal medicine. The factors that most strongly influenced respondents' specialty preferences were the specialty's perceived stress levels and working hours, whereas the least influential factors were the specialty's perceived prestige and role models in the specialty. Women's specialty preferences were significantly more influenced by their family than men's. Men were substantially more influenced by specialties' perceived action-orientation and stress levels than women. Insights: Gender significantly influences medical trainees' specialty preferences in Jordan. Women tended to prefer specialties that provided greater work-life balance, such as family medicine, pediatrics, obstetrics and gynecology, and dermatology, while men were more drawn toward competitive and profitable surgical specialties like orthopedic surgery, neurosurgery, urology, and general surgery. Additionally, family had a stronger influence on women's decisions, likely due to cultural and social expectations prioritizing marriage and family for women. Career counseling and mentorship programs are needed to provide guidance, support, and networking opportunities that can help women overcome barriers and biases that may hinder their career advancement.

Background. Despite their impact on children's health and well-being in the U.S., race and racism are not routinely discussed during pediatric outpatient visits. It is unclear whether families want to discuss race and racism with their pediatrician and - if so - how pediatric residents should be trained to facilitate these conversations effectively. Objective. We explored the perspectives of physician parents, community members, and pediatric residents on discussing race and racism during outpatient pediatric visits as part of a needs assessment to inform the development of a curriculum to teach pediatric residents how to discuss race and racism with families in the primary care setting. Methods. We recruited pediatric residents (n = 6), physician parents (n = 6), and community members (n = 2) to participate in focus groups. Participants were divided into focus groups based on their stakeholder role and self-identified race. We recorded and transcribed focus group dialogue and used thematic analysis to examine the data. Results: Participants expressed hesitancy regarding discussions about racism between families and their pediatrician, given possible unintended consequences. Participants felt that shared experiences amongst patients and providers could help improve provider and patient comfort during these conversations. Black physician parents and community members highlighted the importance of celebrating children's racial identities and avoiding preemptively broaching conversations about racism. White physician parents and residents, in contrast, expressed desire for standardized guidance and suggested phrasing to improve their comfort. To effectively train pediatricians to have conversations about racism, all participants expressed the importance of pediatricians learning about racism's effects on children's health, both broadly and locally. To learn this information, community members felt community involvement would be most beneficial, whereas pediatric trainees and white physician parents felt standardized training with role play would be most helpful. Conclusions. Facilitating conversations about race and racism in the outpatient setting requires a patient-and family-centered, nuanced approach. Educators developing curricula to teach trainees how to have these conversations should consider including information on how racism impacts children's health, both broadly and locally. Recognizing the divergent perspectives between stakeholder groups, educators may consider developing structured, longitudinal curricula focused on the current and historical health impacts of race, racism, bias, and discrimination, incorporating experiential learning in the community setting instead of focusing on developing curricula specifically focused on teaching trainees how to discuss racism in the primary care setting.

Introduction. Medical trainees often confront a healthcare system entrenched in longstanding social harm, including racism, sexism, and homophobia. Yet, advocacy remains vaguely addressed in U.S. medical training, leaving trainees without structural support as they engage in acts of professional resistance to social injustice. This study explores medical trainees' development of a "resistor identity" and how this identity shapes their professional identity as physicians committed to challenging systemic injustices. Methods. Using a qualitative approach, we applied constructivist grounded theory to semi-structured interviews with 18 medical trainees known for engaging in professional resistance. Data collection spanned two interview rounds, 10 months apart. Drawing from Selinger's professional development identity framework of "being" and "becoming," and Syed and McLean's identity integration theory, our analysis examined the origins of resistor identity and its dynamic interrelations with professional identity. We employed constant comparative analysis to identify patterns. Results. Findings reveal that trainees' resistor identities emerge in response to conflicts between their professional roles and their desire to address systemic injustice within medical education and practice. Three relationships between their resistor and professional identities were identified: (1) Conflict: Trainees perceived tension between their resistor and professional identities, and avoided the former being assimilated into the latter to maintain awareness of systemic injustice. (2) Intertwining: Some saw these identities as deeply connected but maintained some level of distinctness. They observed role models who demonstrated ways to help both identities coexist harmoniously. (3) Integration: Some trainees experienced an initial conflict or intertwinement between identities, but later achieved integration, transforming their professionalism to include humane concerns and mature expressions of resistance. Discussion. These interrelations are fluid rather than fixed or mutually exclusive. Trainees critically reflect on what it means to be a physician, actively expanding their professional identities to incorporate values of advocacy and justice. The resistor identity allows trainees to resist privileged norms of the profession while still fulfilling their roles as competent and effective physicians. Findings highlight both challenges and possible pathways to professional identity integration, while call for acknowledging advocacy and professional resistance as key roles for future physicians.

Medical education is witnessing a growing need for disability support, particularly for cognitive and psychiatric disabilities, yet many medical learners do not receive the necessary accommodations. These barriers may arise from uncertainty in how to approach multifaceted challenges, lack of disability recognition by both learners and educators, fear of stigma, and unclear or inadequate institutional policies and support systems. This case study about a urology resident in a U.S. training program, presented from the viewpoint of his competency development coach and residency program leadership with case description and insights from the resident, explores how adopting a Master Adaptive Learner (MAL) approach to identifying multiple intertwined challenges enables targeted remediation and disability support efforts. While situated in a U.S. surgical graduate medical education program, this case offers insights that can be helpful to medical educators in a variety of settings about how to effectively support struggling learners, while emphasizing the importance of early identification, tailored accommodations, and the value of creating an inclusive learning environment for all medical learners. By modeling how the ability to be vulnerable is a strength in the learning environment, this case aims to reduce the stigma associated with having learning requirements that fall outside a program's standard curriculum. Ultimately, this paper advocates for shifting the remediation process from a stigma-laden experience to one that fosters growth, helping both learners and programs evolve.

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.