Teaching and Learning in Medicine最新文献

Introduction: Continuous quality improvement (QI) is crucial for successful curricular implementation and innovation in health professions education (HPE). Central to this is a favorable Quality Culture (QC), one that promotes people's beliefs, commitment, engagement, communication, and collaboration. However, the concept of QC remains underexplored in low-income settings, resulting in a limited understanding of its constitutive elements and how to foster them. This study was conducted to identify elements considered essential for fostering QC in Ethiopia's HPE institutions. Methods: In June-July 2024, we conducted a Modified Delphi study with a panel of 31 academic leaders, faculty, and students who had an interest and three years of experience in QI, accreditation, and/or HPE management. Using the Quality Culture Inventory tool, we identified 31 elements. Over three rounds, the panelists used a three-point scale to rate online the importance of targeting each element to foster QC, and proportions were calculated. We retained elements with ≥70% agreement as "essential" and discarded those with ≥70% agreement as "not so important." We reviewed the remaining elements in light of the panel's comments. At the end of each Delphi round, we shared feedback reports with the panelists, which guided the subsequent Delphi rounds. We concluded the ratings after the third round. Results: Of the 31 elements, 18 were considered "essential" to foster QC. Five elements reflected the individual psychological dimension: belief, commitment, participation, connectedness to quality goals, and leading change. Three elements reflected the collective psychological dimension: strong peer support, functional working groups, and experience-sharing practices. In the formal structural quality assurance (QA) dimension, priority was given to the presence of decentralized quality departments that facilitate regular self-assessments. Seven other elements were related to academic leadership and human resources development. Conclusions: To foster QC, HPE institutions enhance academic leadership, staff development, and motivation. Addressing people's psychological factors strengthens their beliefs, commitment, participation, connectedness to the quality agenda, and mentality for leading change. Equally important is decentralization of quality departments to enhance their responsiveness and ownership.

Background: The Ethiopian Ministry of Health introduced medical licensure examinations to maintain high standards in medical practice and build public trust in healthcare professionals. Studies also suggested significant issues in clinical competence among Ethiopian junior doctors as well concerns regarding unlicensed practice. Given the need to ensure safe health care, we investigated the psychometric properties of the multiple-choice items comprising the Ethiopian national licensing exam (NLE). These analyses help to provide an argument for the validity and reliability of the test scores. Method: We used a cross-sectional study design to analyze data from three cohorts of undergraduate medicine licensing examinations in Ethiopia (2020-2022, N = 2,213). Using Classical Test Theory, we assessed the psychometric properties of 600 MCQ items with 2400 single best answer choices, specifically item difficulty, item discrimination, and the number of nonfunctional distractors, and scale reliability. We provide results regarding the overall test and its sub-domains. Results: Ethiopia's undergraduate medical licensure examination demonstrated acceptable reliability (Alpha > 0.80), with significant variability in item difficulty and examinee performance. Although these results indicate a sufficiently defensible exam, our results point to issues regarding item statistics, especially a high number of nonfunctional distractors. Conclusions: This study provides first evidence regarding the psychometric soundness of the Ethiopian NLE. However, a significant number of items should be carefully reviewed and possibly revised. As the examination is relatively new, ongoing refinement to item-development and review processes is essential to improve and ensure its quality.

Phenomenon: There is a crucial need to more deeply understand the impact and etiology of bias toward persons with developmental disabilities (PWDD). A largely unstudied area of concern and possible intervention is the portrayal of PWDD in medical education. Often, medical photographs portray PWDD with obscured faces, emotionless, and posed in an undignified way. This exploratory, qualitative study aimed to explore how photo representations of PWDD influences medical students' attitudes and beliefs toward disability. Approach: We recruited 10 medical students from a single medical school in the northeastern United States to participate in in-depth, individual semi-structured interviews via Zoom. During the interviews, we asked students to reflect on and respond to two image sets of PWDD: a standard image set, which were photos from medical textbooks, and a positive image set, which were photos from the U.S.-based disability nonprofit, Positive Exposure. Using thematic analysis underpinned by the Health Stigma and Discrimination Framework, we coded and organized the transcripts into four themes that characterized participants' attitudes and beliefs about PWDD. Findings: The four themes we identified were as follows. Humanization vs. dehumanization: Standard imagery characteristics (e.g., black bars, unnatural posing, lack of clothing) were perceived as dehumanizing and raised concerns about consent and autonomy, whereas positive imagery characteristics (e.g., clothing, natural poses, nonclinical settings) were seen as humanizing and enhanced perceptions of agency. Quality of life: Standard imagery often led to assumptions of compromised quality of life, while positive imagery suggested a good quality of life. Discomfort vs. comfort with communication in a clinical setting: Dehumanizing portrayals increased perceived difficulty in establishing rapport, while humanizing imagery mitigated these perceived barriers. Diversity: Image sets showcasing a diverse spectrum of presentations for a given diagnosis were valued for medical education. Insights: We conclude that photographic representation of disability in medical education can influence medical students' attitudes and beliefs about PWDD. Photographic elements can either humanize or dehumanize, with humanizing representation leading to more positive attitudes and therefore also an educational benefit. Thoughtful and inclusive visual content is needed in medical education to encourage positive attitudes and foster a more empathetic healthcare environment. Our results support future plans to further investigate how photo representation affects attitudes in a larger sample. Additionally, our study's insights contribute to the ongoing initiative Textbook Beauty, providing guidance for the selection of photography to improve attitudes toward disabilities.

Abductive thematic analysis blends empirical observations with theoretical frameworks, fostering a continuous and dynamic exchange between research evidence and theory. It is distinct from other forms of analysis as it is underpinned by pragmatism and is flexible in its adoption of theory to best answer the research question. As a result of an interplay between theory and data, a surprising, puzzling, or anomalous finding may lead to new insights. This flexible approach to inquiry can draw from theories dependent upon what is best able to explain the data. This results in a theoretically informed explanation for empirical phenomena, which may in turn unveil unique insights about theories, making it a valuable tool across diverse research domains in medical science. The guidelines in this paper aim to illuminate abductive thematic analysis, steering the reader through each step toward maximizing novel theoretical contributions and fostering a comprehensive understanding for researchers and educators.

The healthcare workforce in the United States does not provide the same standard of care for people with disabilities as for nondisabled people. Many academic medical institutions do not routinely offer disability-conscious medical training, and many clinicians and medical educators feel ill-equipped to incorporate anti-ableist learning goals into their curricula. Drawing on a critical review of the literature and interviews with medical educators, representatives of professional organizations, and disability advocates, this article presents promising practices for disability-conscious undergraduate medical education. Disability-conscious education, which is grounded in the insights of disability studies and disability rights and justice frameworks, is distinguished from disability-specific education, which may not extend beyond biomedical models of disability. First, we define current approaches to teaching about disability, highlighting limitations and opportunities for further development. We then identify and analyze approaches to teaching about disability that support the development of disability consciousness among learners. With attention to both curricular format and theoretical frameworks, we offer concrete approaches that medical schools can take to equip students with the knowledge, attitudes, skills, and practices they need to provide equitable care for patients with disabilities.

Research is never truly neutral; all research is inherently subjective because it is shaped by who conducts it, how they think, and the systems they operate within. Paradoxically, despite reflexivity's critical intent - a practice for recognizing and addressing researcher influence - it too often becomes a superficial checkbox exercise that fails to meaningfully challenge deeper structural and systemic inequities. As a result, Health Professions Education (HPE) research often reinforces global power imbalances, privileging Western perspectives while excluding knowledge from the Global South and marginalized communities. This article advocates for Critical Reflexive Praxis (CRP), an approach grounded in Critical Theory, that combines self-reflection with deliberate action to disrupt power dynamics and promote equity in research. CRP extends beyond traditional reflexivity by interrogating and transforming the underlying structures that shape knowledge production and dominant research practice. By adopting CRP, researchers can challenge entrenched hierarchies, include and amplify marginalized perspectives, and create research that fosters meaningful social transformation. This article offers practical guidelines for enacting CRP across individual, interpersonal, local, and global levels during HPE research planning, paving the way for more equitable and impactful contributions to HPE and beyond.

Traditional student evaluations of teaching and educator portfolios do not adequately assess the breadth and depth of medical educators' efforts. Current processes use limited perspectives, focus on a small portion of educators' work, and emphasize subjective opinions, which introduce bias. Use of these data for high-stakes decisions such as academic promotion contributes to inequitable career advancement. We propose a holistic, growth-focused, behaviorally anchored system of evaluation which incorporates perspectives of the learner, peers, and self, and which examines the full scale of educator activities from a single session, to course design, to development of educator skills over years.

The involvement of people with lived experience (patients) in medical education offers a unique opportunity for students and residents to access personal and collective knowledge about the lived experience of health, ill health, and medical care. Involvement also has the potential to elevate the role of people with lived experience and their knowledge within medicine by providing a model for meaningful collaboration and partnership. However, involvement has been critiqued by critical disability scholars for its potential to harm without leading to meaningful change in professional knowledge or practice. In this article, we (two educators with lived experience and an academic psychiatrist) describe the development and delivery of an annual lived-experience presentation about psychosis for the second-year class of a large, urban medical school in Canada. We describe our reflexive process attempting to enact meaningful involvement and disrupt the uneven power relations that shape and constrain this work, in a setting where the risks of exploitation, tokenism, and co-optation are significant. Our goal has been to re-imagine the "patient panel," which puts significant limits on the position of patients as knowers. By re-defining roles and shifting power from faculty to lived experience educators, we have aimed to present important non-medical ideas about psychosis and how to effectively support people who experience it, while disrupting interpersonal and structural bias.

Self-regulated learning (SRL) can significantly improve academic achievement and clinical performance. The clinical clerkship is a crucial setting for reinforcing and extending SRL skills and behaviors into clinical practice. However, learning in clinical settings is often opportunistic and contextual, requiring diverse instructional strategies and tailored learning opportunities. Studies from the past two decades have indicated challenges in implementing SRL strategies particularly in Asian countries. While many of the pedagogical approaches used in medical education include aspects of SRL theory, a comprehensive overview of effective SRL instructional strategies in clinical clerkships is lacking. We reviewed all studies (published between January 2012 and May 2024, identified via systematic search of EBSCOhost, PubMed, ScienceDirect, Scopus, and Web of Science) that discuss instructional strategies influencing SRL among clinical clerkship students, in general, and with special reference to the Asian context. Twenty seven articles were included in the final analysis. We conducted convergent integrated synthesis on the data extracted from all included studies to generate categories and themes. SRL instructional strategies reported included implementing learning plans and goal setting, operationalizing formal mentoring and feedback processes, utilizing technology-enhanced learning, facilitating collaborative group learning, providing simulation-based learning experiences, and applying experiential learning strategies. When implemented effectively, such strategies were shown to promote self-regulated learning, motivational beliefs, self-monitoring, and self-reflection. Faculty support, mentoring and timely feedback were crucial in successfully implementing SRL strategies. Incorporating SRL into existing curricula was ideal for ensuring feasibility and long-term sustainability. Limited research from the Asian region indicates that SRL has not been used to its full potential in Asian medical education. Asian medical students' SRL potential could be maximized with shared roles of students and teachers in a student-driven approach. Medical educators should take responsibility for providing opportunities and a conducive environment to foster SRL among clinical clerkship students. Future research should prioritize longitudinal, experimental studies with comparison groups and objective SRL outcome measures to rigorously evaluate the impact of instructional strategies in the clinical clerkship context.

Phenomenon: Physician shortages are common in underserved populations globally, and strategic medical school programs have been associated with increased physician retention. Despite Venezuela's physician emigration crisis and its international impact, there is incomplete understanding of variables influencing emigration decisions and potential solutions to increase retention. Approach: Between January and June 2023, an anonymous, online questionnaire surveyed recent Venezuelan medical school graduates (2015-2021) living and practicing within and outside of Venezuela. Mixed-methods questions explored perspectives about medical training in Venezuela, desires for alternative medical school programming and professional development opportunities, and factors influencing emigration decisions. Quantitative responses were analyzed with descriptive statistics. Qualitative data were analyzed with a deductive content analysis approach to code for key themes. Findings: Among 312 respondents representing all eight national universities and 17 specialties, 40% had emigrated. Most respondents agreed that care for underserved communities was a positive aspect of training (83%), but nearly all agreed that insufficient hospital resources negatively affected training (97%) and limited the practice of evidence-based medicine (91%). Desires for new curriculum centered on topics of Medical Informatics & Technology, Research, and Public Health. Of all drivers of migration, 20% were related to medical training (versus individual- and societal-level drivers), including desires for improved professional development opportunities, higher quality of training, and modified work culture. Insights: This diverse sample of Venezuelan physicians expressed a core tension, common to physicians in low-resourced settings globally, between vocation to serve underserved populations and lack of economic and professional development opportunities. Medical education interventions to stimulate physician retention could include targeted curriculum to prepare students for systems-based practice, programs to address moral distress, and engagement with higher-resourced peer institutions to provide desired clinical and research collaborations.