Teaching and Learning in Medicine最新文献

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.

Phenomenon: Sexual and gender minority (SGM) identifying individuals experience worse health outcomes compared to non-SGM identifying counterparts. Representation of SGM individuals within medical schools may improve the delivery of more equitable healthcare through reducing biases and normalizing SGM presence within healthcare spaces. Approach: Our initial aim was to explore the extent to which role models may influence personal SGM identities within medical schools in the United Kingdom, using an interpretative phenomenological approach. This methodology allowed us to develop meaning from, and give voice to participants' relationship with their bespoke experiences, respecting differing narratives within the broad 'SGM' umbrella, rather than attempting to establish commonalities. Semi-structured interviews were conducted with five medical students and three medical school faculty within three medical schools, who identified as SGM. Due to a lack of gender minority identifying participants, we unfortunately could not adequately speak to their experiences, and therefore narrowed our eventual focus to sexual minority (SM) individuals. Findings: The developed themes followed a cyclical process of: (1) role model identification; (2) role model selection, influenced by matched wider identities including generation, hierarchy and power; (3) trait assimilation, particularly where identity deficits were perceived; and (4) identity projection, where students used role models to both emulate comfortable SM identity projection, and become advocatory role models themselves. Throughout, participants described role models as multifaceted in their direction (vertical and horizontal), influence (positive and negative) and locus of effect (as individuals, and as part of a collective). Unexpectedly, identity, power, and hierarchy-matching meant peer-to-peer role modeling was often experienced more positively than vertical faculty-to-student role modeling. However, as expected, heteronormativity exerted an inhibitory effect on this process. Insights: We built upon existing social cognitive paradigms to develop a 'double-funnel' model to represent how social contexts can map onto individual SM identities and vice versa, mediated by role models. The triangulation of these three aspects in relation to medical education presents novel understandings to the field. Greater explicit institutional support of student-led SM societies, and facilitation of the presence and discussion of SM symbols and personal identities within professional spaces, may go a long way in redefining 'normativity' in medical schools.

For over half of a century, there have been calls for greater patient and community involvement in U.S. medical education. Accrediting agencies, as the regulatory authorities for medical education, develop policies that impact every program in the U.S.; they have the ability to support patient involvement across the medical education system. In this article, we first review the requirements of U.S. accrediting agencies for undergraduate and graduate medical education to involve patients in educational programs. While agencies have patient members on their committees, they do little to encourage patient involvement through their standards or procedures. We then describe opportunities for accreditation to support patient involvement across teaching and learning activities, curriculum design and evaluation, policymaking and governance, and scholarly endeavors. We link these opportunities to specific standards that could be revised or have their data reporting requirements adjusted. U.S. agencies could also follow the examples of their counterparts outside the U.S., which have created new standards to encourage patient involvement. Ensuring patient representation on educational programs' governing and policymaking bodies is one among many immediate actions that could be taken by accrediting authorities to encourage system-level reforms. As medical school and residency training represent the beginnings of decades of practice for physicians, properly involving patients would maximize benefits for learners, educators, and society.

In the spirit (but not exact format) of Mr. Swift's "A Modest Proposal," this article is written to challenge the capitalist response to supply and demand and highlight the downsides of applying it indiscriminately to medical education. We approach this piece as satire and a pointed critique of our current approach to the training of physicians in the hopes that readers view it in that regard. We have chosen modern dairy production intentionally as an analogy to frame our criticism. The medical field's focus on rapid expansion has inevitably led to increased standardization without acknowledgment that our current approach to training physicians requires an efficiency that stifles individuality, positions diversity of medical students as dangerous, and uses professionalism and burnout as means of control. This creates a bewildering and incomprehensible system where aspiring doctors enter what they believe to be a noble profession, only to face overwhelming workloads and debt, discover limited relevance between their medical education and contemporary healthcare realities, and find that direct patient interaction now constitutes a small fraction of physicians' daily responsibilities.

Medical education plays a critical role in fulfilling medicine's social contract to improve health. An equitable medical education program is characterized by a sense of belonging, trainee-centered learning, transparent expectations, and an anti-oppressive learning environment. Achieving equity requires identifying and addressing systemic inequities and biases within educational policies and practices. Despite the importance of program evaluation and educational continuous quality improvement (ECQI) in medical education for decision-making, accreditation, and transformation, these efforts often have not prioritized equity. This paper examines the evolution of program evaluation in medical education and highlights the need for a paradigm shift that centers equity and justice. A case example illustrates how traditional evaluation metrics, such as board examination pass rates and mean learner satisfaction, obscure the experiences of minoritized learners. The authors propose recommendations for embedding equity into program evaluation and ECQI, aligned with the concept of equity described by the World Health Organization. These recommendations include establishing a shared commitment to educational equity, building equity-centered evaluation teams, employing social justice-oriented evaluation approaches, attending to the experiences and outcomes of minoritized participants, focusing on growth and success, and employing a critical lens. These strategies aim to transform evaluation practices to reflect a commitment to equity, ensuring that program evaluation not only measures outcomes but also identifies and addresses the underlying causes of inequities. By fostering an equitable habit of mind and building a quality culture that prioritizes continuous reflection and improvement, medical education can create a fair, supportive, and enriching environment for all learners. Ultimately, centering equity in program evaluation and ECQI is an important step in building equitable educational systems that lead to equitable healthcare outcomes for patients and communities.

While ableism and racism have been acknowledged separately as harming, marginalizing, and excluding medical students, research has not explored their interconnected workings in the lives of disabled and racially marginalized medical students. In this qualitative interview study, we used theoretical and heterogenous sampling to recruit US racially marginalized disabled medical students. The semi-structured interview guide and analysis process used the seven DisCrit tenets as sensitizing lenses to identify counterstories, further using horror story tropes as analytic metaphors to deepen analysis and strengthen the narrative. The 12 participants included first- through fourth-year medical students ages 24-29, with a range of disability experiences, races and ethnicities, and gender identities. Participants were impacted by both racism and ableism inside a house of horrors while strategically fighting those horrors. Participants entered medical school despite edicts against trespassing, indicating their intersection of race and ability was not welcome. Once inside, learners found themselves trapped in a hall of mirrors, fighting for accommodations and survival in medical school. Navigating the house, it became clear that, as in horror stories, the call was coming from inside the house: those responsible for support were often agents of discriminatory systems. Yet participants fought systemic injustices and built misfit squads with others for protection. Participants intentionally left something akin to an apocalyptic log, to show that they existed and to help future generations of trainees. Our analysis illuminates horrifying experiences and resistant action at the nexus of racism and ableism in U.S. medical education. Rather than offer solutions, we invite readers to grapple with the discomfort of this horror.

Background: Time can serve as a form of oppression when one has control over another's schedule, activities, and timetables. Yet, time as a form of oppression has received little attention in medical education. Students who are considered marginalized, such as low-income (LI) students and LI/first-generation (FGLI) students, have a strained relationship to time because of their unique social positions. In this study, we investigated the temporal experiences of LI and FGLI students using the language they used to talk about time. Methods: This was a secondary analysis of a larger dataset that interviewed 42 students, recruited via listservs and social media. We completed the original interviews between November 2021 and April 2022 and conducted the secondary analysis in 2024. Using methodological bricolage, we analyzed the interview data by: (1) identifying excerpts where a participant discussed time, (2) using functional linguistics to examine these excerpts for participants' representation of agency with respect to time, and (3) analyzing the data for evidence that participants created simultaneous temporalities (i.e., historically contextualized experiences of time). We interpreted agentic acts as a form of resistance, one that is understudied in medical education and resistance studies. Results: LI students resisted medical education's expectation of time by maintaining multiple, simultaneous temporalities that connected them to their communities, family, and themselves. They took time away from medicine to engage in activities including teaching, mentoring, and connecting with others in their communities. They reclaimed time to reflect the values they grew up with and invested time in themselves to support who they are as a person, beyond being a physician. Conclusions: Though the concept of time has received attention in medical education literature, less attention has been paid to time as mechanism for suppressing students' other identities so that a professional identity can be created. This study demonstrates that LI students are aware of this coercive act and actively resist the norms and expectations of medical education by creating new temporalities. These additional temporalities offer glimpses into acts of resistance as protection and promotion; protecting what students care about and promoting a new way of being in medicine.

Despite widespread calls for greater inclusion of disabled people in the healthcare workforce, significant barriers remain. These barriers exist even before admission to training, when applicants are considering study options and future careers. In Australia and Aotearoa/New Zealand (NZ), the Medical Deans of Australia and New Zealand (MDANZ) have developed guidelines for inclusive pre-admission practices, but the extent to which these are enacted is unclear. This study aimed to explore the extent to which Australian and NZ schools have adopted these guidelines and whether their websites communicate to prospective applicants in a way that explicitly recognises disability as a valued dimension of diversity. We used these data to develop a set of reflective questions intended to help medical schools improve their pre-admission communication to applicants. In January-September 2024, we conducted an audit and content analysis of all Australian and NZ public-facing medical school websites. Domains examined included the use of Inherent Requirements and/or MDANZ Guidelines for Inclusive Medical Education and how these documents framed program requirements from organic or functional perspectives. We also explored the accessibility of relevant information, the transparency of pre-admission discussions, and identified where schools framed disability as a deficit versus using positive and strengths-based language. While we found examples of inclusive practices, many schools could improve the clarity and framing of the information provided to applicants. Many schools framed disability as a deficit or avoided explicit reference to disability. Clear information regarding procedures for confidential discussion of applicant circumstances and access to accommodations prior to admission was often absent, potentially leaving applicants uncertain about the impact of disability disclosure. Only half of the schools referenced the MDANZ Guidelines. Those that used Inherent Requirements often employed organic framing which did not acknowledge the role of accommodations. Establishing the state of current practice illuminates opportunities to make medical programs more inclusive from the early stages of the student lifecycle. These findings illustrate the potential gap between policy and practice. Here, we identify the practical importance of reviewing pre-admissions communication through a disability-inclusive lens, and provide a series of recommendations and reflective prompts to support medical schools as they work towards more inclusive practice.