Teaching and Learning in Medicine最新文献

Phenomenon: Problem-based learning (PBL) has been widely adopted in medical schools across the globe. However, the dynamics of discourse moves in time sequences during such learning remain underexplored. This study investigated discourse moves used by PBL tutors and tutees to facilitate collaborative knowledge construction, and adopted sequential analysis to unpack the temporal dynamics of such moves during PBL knowledge construction in an Asian context. Approach: This study's sample comprised 22 first-year medical students and two PBL tutors at an Asian medical school. Two 2-h PBL tutorials were video-recorded and transcribed, and notes were made about the participants' non-verbal behaviors, including but not limited to body language and technology use. Descriptive statistics and visual representations were used to discern participation patterns as they evolved over time, and discourse analysis was applied to identify specific types of teacher and student discourse moves within knowledge construction. Lastly, lag-sequential analysis (LSA) was adopted to understand the sequential patterns of those discourse moves. Findings: The PBL tutors mainly used probing questions, explanation and clarification, compliments, encouragement, affirmation, and requests when facilitating PBL discussions. LSA revealed that discourse moves had the following four major paths. Teachers' content-related questions elicited both lower- and higher-level thinking from students; teachers' statements mediated between students' thinking levels and teachers' questions; there were relationships among teachers' social-facilitation discourse, students' thinking modes, and teachers' statements; and there was a sequential relationship among teachers' statements, students' facilitation, teachers' process-related discourse, and students' silences. Insights: This study revealed the importance of using probing questions to facilitate students' knowledge construction as they proceeded from lower- to higher-level thinking. This study also fills a gap in the current literature by adopting the innovative LSA methodology to explore teachers' and students' discourse move sequences in PBL. The results have important practical implications for PBL tutors regarding when and how to facilitate their students' collaborative knowledge construction.

Phenomenon: The dearth of disability-specific education in United States medical schools and residency programs has perpetuated health care inequities experienced by people with disabilities. In this study, we surveyed internal medicine primary care residency program directors about the disability-specific education they offer their learners, their attitudes toward physicians' preparedness to care for people with disabilities, and their perceived challenges to offering more robust disability-specific education. Approach: We developed an on-line survey and forwarded it in 3 weekly emails during October of 2022 to 104 primary care residency program directors. We collected basic information about the residency programs and queried whether they were providing disability-specific education to their residents, which topics were being covered, and perceived barriers to offering additional disability-focused curricula. Data analyses included descriptive statistics, chi-squared, and independent samples t-tests. Findings: Forty-seven program directors responded (response rate 45.2%). The largest plurality of programs was in the Northeast, their average number of primary care residents was 15.6, most (67.4%) hosted primary care clinics in hospitals or academic centers, and 55.6% had affiliated divisions or departments of rehabilitation medicine. The majority of respondents felt that both internists and their own residents (88.3% and 77.8%, respectively) are inadequately educated in the care of people with disabilities, yet only 13 (28.9%) offered disability-focused curricula, and they tended to be narrow in scope. Only 8 of those 13 respondents (61.5%) reported that their disability curricula were required, rather than optional. Participants listed a number of barriers to implementing disability-focused education including a lack of advocacy for such work (65.2%), lack of time in the curriculum (63.0%), lack of expectation by educational governing boards that physicians understand disability-specific care considerations (60.9%), and lack of affiliated expertise in the care of people with disabilities (52.2%). Insights: While the program directors training future primary care physicians largely understand that physicians are inadequately prepared to offer equitable health care to individuals with disabilities, few of them are offering disability-specific education to their residents and most see significant barriers to doing so.

Phenomenon: As the first stage of a large-scale educational design research (EDR) study focused on the complex problem of providing authentic experiential "hands-on, minds-in" learning opportunities online during a pandemic or other exigency, we conducted a literature review and we interviewed Turkish academic staff and students about their experiences during the first year of the COVID-19 Pandemic. ApproachWe interviewed faculty members, faculty members of medical education departments, and medical students from both public and private medical schools in Türkiye between October 1 and December 31, 2020. Working in pairs, we analyzed the transcripts of 49 interviews using open qualitative coding methods with satisfactory levels of coefficients of agreement. FindingsWe defined six major themes from the qualitative analysis: 1) Fear and concern were the most common reactions when first encountering the pandemic; 2) Teaching methods during the pandemic were primarily unidirectional from faculty to students. This largely one way transmission of information occurred both synchronously and asynchronously; 3) Technological support during the pandemic shutdowns was found to be challenging for both faculties and students; 4) Evaluation of learning during the pandemic was opportunistic and had questionable rigor; 5) Healthy communication was valued by both faculty and students using an array of different tools including social media; and 6) The pandemic had both negative and positive impacts on the educational processes experienced by students and provided by faculty and resulted in recommendations for new approaches to teaching and learning in the future. Medical students were primarily concerned about the susceptibility to COVID-19 of themselves and others, and how the pandemic would affect their progress toward completing their studies. Faculty were primarily concerned about the capacity of online learning to provide clinical learning opportunities and the difficulties of assessing student clinical skills using online modalities. Medical education specialists were primarily concerned about the quality of educational opportunities offered online. InsightsOur findings were similar to other studies conducted in the USA, China, United Kingdom, and other countries. However, the interviews revealed interest among faculty and medical education specialists for further investigation of experiential or active learning models that could be applied in medical education regardless of whether the delivery mode is face-to-face, online, or most likely, blended. In the next stage of our larger scale EDR study, we will design and construct prototype learning environments that incorporate experiential, active, and authentic learning design principles.

Phenomenon: Developing foundational clinical procedural skills is essential to becoming a competent physician. Prior work has shown that medical students and interns lack confidence and competence in these skills. Thus, understanding the student's perspective on why these skills are more difficult to acquire is vital for developing and reforming medical curricula. Approach: This study explored procedural skills learning experiences of medical students with qualitative methods. Through purposive sampling, 52 medical students from the third, fourth, and final years were selected for inclusion. Data were collected using six audio-recorded, semi-structured focus group discussions. Transcripts were manually coded and analyzed using inductive content analysis. Findings: Students provided rich and insightful perspectives regarding their experiences in learning procedural skills that fell into three broad categories: 1) barriers to procedural learning, 2) reasons for learning, and 3) suggestions for better learning outcomes. Students described a range of barriers that stemmed from both patient and clinician interactions. Students were reluctant to make demands for their own benefit during clerkships. The most commonly expressed reason for wanting to learn procedural skills was the desire to be a competent and independent intern. The motivators suggested that students felt empathetic toward interns and visualized a successful internship as a learning goal. Participants suggested peer learning, improved teaching of procedural skills, assessments, and feedback to improve their learning. Insights: This study generated valuable information to promote critical reflection on the existing curriculum and pedagogical approaches to procedural skills development. Medical educators need to sensitize the clinical teachers to student perspectives and what students are really learning to make impactful changes to teaching and learning procedural skills. Students' self-advocacy skills and self-directed learning skills need to be developed for them to seek out learning opportunities and to promote life-long learning. Lessons from this study may also apply to curriculum design in general, especially in teaching clinical skills. Empowering the learner and embracing a learner-centered approach to teaching and learning procedural skills will benefit future clinicians and their patients.

Construct: Psychological distress among students is a growing concern in medical education, even more so with the advent of COVID-19 pandemic. Anxiety is among students' mental health issues. High and persistent anxiety has many negative impacts on students' academic and personal life. Early detection is essential for timely intervention. Background: Currently, medical student anxiety is assessed using tools primarily designed for psychiatric purposes. Despite their excellent validity evidence, these tools contain sensitive items and do not explore stressors related to clinical activities. There is a need for contextualized tools to better identify anxiety-provoking factors specific to the medical education environment. Approach: We previously developed the Crisis Experience Rating Scale (CERS-7), a short screening tool to identify early on anxious students participating in clinical activities during the first wave of the COVID-19 pandemic. The present study sought to produce further validity evidence for the CERS-7. Medical students in their clinical years at two Swiss and one French medical school, all involved in COVID-19 clinical activity during the second wave of the pandemic, completed the CERS-7 and the State Anxiety Inventory (STAI-A), the best known and widely used tool to measure for general anxiety. We evaluated internal structure using confirmatory factor analysis (CFA) and relation to other variables using linear regression (LR) and receiver operating characteristic (ROC) curves with thresholds defined using the Youden index. Findings: There were 372 participants. CFA confirmed the two-factor structure of the CERS-7 scale from first-wave dataset. The CERS-7 total scale and subscales demonstrated validity evidence in relationship to the STAI-A scores and categories. A CERS-7 total scale score < 27.5 identified 93% of severely anxious students. Conclusion: The CERS-7 produces reliable scores to use for monitoring anxiety status when assigning students to clinical settings as well as for improving training conditions during clinical crisis.

Problem: Visual racism refers to both the underrepresentation and inappropriate representation of darker skin types in medical education. By not teaching medical students and resident physicians to recognize common conditions in darker skin, it perpetuates biases that contribute to healthcare disparities for racial and ethnic minoritized groups. In this paper we describe our efforts to engage in institutional anti-racism work by addressing imbalances in representation of darker skin types in visual teaching images within our institution's curriculum. Intervention: We initially surveyed preclinical medical students regarding their perceptions of skin color representation in two courses. Researchers recorded the skin types of all teaching photographs in these courses in 2020. We then provided feedback and education to faculty, proposing that they increase brown and black skin color representation in educational content. During 2021, we reviewed the same courses and surveyed students again to ascertain the implementation and impact of our proposal. Context: We applied our intervention to two courses, Host & Defense (H&D) and Skin, Muscle, Bone, and Joint (SMBJ) since both courses utilize a large number of teaching images. Impact: From 2020 to 2021, both H&D and SMBJ significantly increased the proportion of visual teaching images that included darker skin types, with an increase from 28% to 42% in H&D and 20% to 30% in SMBJ. Significantly more students in the courses' 2021 iterations (73% in H&D, 93% in SMBJ) felt that lectures had appropriate representations of darker skin types when compared to students who took the course in 2020 (8% in H&D, 51% in SMBJ). Students in 2021 felt more confident in recognizing dermatological signs and symptoms in patients with darker skin than students in 2020. The majority of students in both 2020 and 2021 reported wanting to see a gradient of skin types for every dermatological condition discussed. Lessons learned: Our work suggests that addressing visual racism can be achieved partly by setting expectations for increased visual representation, collaborating across educational departments, and establishing clear metrics for assessing implementation. Future interventions will require a continual feedback loop of monitoring learning material, assessing faculty and student perception, refining resources, and recommending revisions to improve visual representation across the entire curriculum.

Phenomenon: Competency-based medical education (CBME) relies on workplace-based assessment (WBA) to generate formative feedback (assessment for learning-AfL) and make inferences about competence (assessment of learning-AoL). When approaches to CBME rely on residents to initiate WBA, learners experience tension between seeking WBA for learning and for establishing competence. How learners resolve this tension may lead to unintended consequences for both AfL and AoL. We sought to explore the factors that impact both decisions to seek and not to seek WBA and use the findings to build a model of assessment-seeking strategy used by residents. In building this model we consider how the link between WBA and promotion or progression within a program impacts an individual's assessment-seeking strategy. Approach: We conducted 20 semi-structured interviews with internal medicine residents at Queen's University about the factors that influence their decision to seek or avoid WBA. Using grounded theory methodology, we applied a constant comparative analysis to collect data iteratively and identify themes. A conceptual model was developed to describe the interaction of factors impacting the decision to seek and initiate WBA. Findings: Participants identified two main motivations when deciding to seek assessments: the need to fulfill program requirements and the desire to receive feedback for learning. Analysis suggested that these motivations are often at odds with each other. Participants also described several moderating factors that impact the decision to initiate assessments, irrespective of the primary underlying motivation. These included resident performance, assessor factors, training program expectations, and clinical context. A conceptual framework was developed to describe the factors that lead to strategic assessment-seeking behaviors. Insights: Faced with the dual purpose of WBA in CBME, resident behavior in initiating assessment is guided by specific assessment-seeking strategies. Strategies reflect individual underlying motivations, influenced by four moderating factors. These findings have broad implications for programmatic assessment in a CBME context including validity considerations for assessment data used in summative decision-making including readiness for unsupervised practice.

Phenomenon: Trainees from racial/ethnic backgrounds underrepresented in medicine (RE URiM) in the United States face challenges of racism and micro- and macro-aggressions during residency. Many have learned to navigate these challenges through successes and failures, but there is insufficient literature providing these lessons to graduating URiM medical students. Our study among medical school alumni explores strategies to help graduating URiM students prepare for success in residency. Approach: We conducted an online cross-sectional survey (Qualtrics) from February to March 2022. Graduates from a Northeast U.S. medical school identifying as URiM were invited to participate. With emphasis on "thriving" in residency training, we solicited rating-scale responses on preparedness for residency and open-text responses on strategies for success. Standard statistical and text content analysis were used to determine findings and themes. We used Word Cloud technology to further explore word frequency and patterns. Findings: Of the 43 alumni contacted, 23 (53%) completed the survey. Participants were trained in various specialties. We identified three themes with regard to strategies for thriving in residency: (1) importance of identifying and seeking early mentorship; (2) importance of identifying and having diverse forms of support; and (3) need for more education on navigating macro/microaggressions. Insight: While advocating for systems-level interventions to create inclusive learning environments, we highlight the gap in trainee awareness of the importance of seeking early mentorship. Our study provides strategies for graduating URiM medical students to succeed in residency based on respondent experiences. These recommendations should inform medical school curricula.

Medical devices are manmade objects existing at the interface between numerous disciplines. They range from as simple as medical gloves to as complex as artificial limbs. This versatility of medical devices and their inherent interdisciplinary nature means that academic courses on them are attended by cohorts of students from varieties of academic backgrounds, who bring with them similarly broad spectra of interests. To satisfy the learning expectations of each and every student in such diverse classes is a daunting task for the instructor. After many years of teaching medical devices at undergraduate and graduate levels at three different universities in the states of Illinois and California, I have come up with an instructional method that solves this challenge by engaging students in the co-creation of the curriculum via selection of their own medical devices of interest and presentation to the class for collective analysis. The threefold presentations are designed so that they reflect an ascent along the hierarchy of a learning taxonomy extending from foundational concepts to critical assessment of knowledge to creative displays of it. In such a way, the students are acquainted with the ability of critical and creative thinking at the expense of rote memorization or inculcation and are prepared to enter the field of medical devices as innovation-centered individuals. The specifics of this new method of instruction are reported here, with the hope that they will be useful to fellow instructors in any interdisciplinary course that benefits from a balance between the rigorous coverage of the instructional material pertaining to engineering and medicine and the flexible selection of topics that comply with students' individual interests.