Teaching and Learning in Medicine最新文献

Phenomenon: Existing literature, as well as anecdotal evidence, suggests that tiered clinical grading systems may display systematic demographic biases. This study aimed to investigate these potential inequities in-depth. Specifically, this study attempted to address the following gaps in the literature: (1) studying grades actually assigned to students (as opposed to self-reported ones), (2) using longitudinal data over an 8-year period, providing stability of data, (3) analyzing three important, potentially confounding covariates, (4) using a comprehensive multivariate statistical design, and (5) investigating not just the main effects of gender and race, but also their potential interaction. Approach: Participants included 1,905 graduates (985 women, 51.7%) who received the Doctor of Medicine degree between 2014 and 2021. Most of the participants were white (n = 1,310, 68.8%) and about one-fifth were nonwhite (n = 397, 20.8%). There were no reported race data for 10.4% (n = 198). To explore potential differential grading, a two-way multivariate analysis of covariance was employed to examine the impact of race and gender on grades in eight required clerkships, adjusting for prior academic performance. Findings: There were two significant main effects, race and gender, but no interaction effect between gender and race. Women received higher grades on average on all eight clerkships, and white students received higher grades on average on four of the eight clerkships (Medicine, Pediatrics, Surgery, Obstetrics/Gynecology). These relationships held even when accounting for prior performance covariates. Insights: These findings provide additional evidence that tiered grading systems may be subject to systematic demographic biases. It is difficult to tease apart the contributions of various factors to the observed differences in gender and race on clerkship grades, and the interactions that produce these biases may be quite complex. The simplest solution to cut through the tangled web of grading biases may be to move away from a tiered grading system altogether.

Phenomenon: Professionalism as a construct is weaponized to police and punish those who do not fit the norm of what a medical professional should look like or behave, more so when medical professionals in training engage in protests for social justice. In addition, professionalism silences trainees, forcing them not to question anything that looks or feels wrong in their eyes. Socialization in medicine, in both the undergraduate and postgraduate training spaces, poses challenges for contemporary medical professionals who are expected to fit the shape of the 'right kind of doctor.' Intersectionality seems to impact how medical trainees experience professionalism, be it intersections of gender, race, how they dress or adorn themselves, how they carry themselves and who they identify as. Although there is literature on the challenges pertaining to professionalism, not much has been written about the weaponization of professionalism in medical training, particularly in the South African context. There is also a paucity of data on experiences of professionalism during or after social upheaval. Approach: This is part of a study that explored the experiences of professionalism of five medical trainees during protests and after protests, extending into their postgraduate training. The main study had 13 participants, eight students and five graduates, who were all interviewed in 2020, five years after the #FeesMustFall protests. For the five postgraduate participants, we looked at how gender, race, hairstyles, adornment, and protests played out in the experiences of professionalism as medical trainees at a South African university. We employed a qualitative phenomenological approach. An intersectional analytical lens was used in analyzing the transcripts of the five graduate participants. Each transcript was translated as the story of that participant. These stories were compared, looking for commonalities and differences in terms of their experiences. Findings: The participants, four males (three Black and one white) and one Black female, were victimized or judged based on their activism for social justice, gender, and race. They were made to feel that having African hairstyles or piercings was not professional. Insights: Society and the medical profession has a narrow view of what a doctor should look like and behave - it should not be someone who wears their hair in locks, has body piercing, or is an activist, least of all if she is a woman, as professionalism is used as a weapon against all these characteristics. Inclusivity should be the norm in medical education.

Issue: Clinical reasoning is essential to physicians' competence, yet assessment of clinical reasoning remains a significant challenge. Clinical reasoning is a complex, evolving, non-linear, context-driven, and content-specific construct which arguably cannot be assessed at one point in time or with a single method. This has posed challenges for educators for many decades, despite significant development of individual assessment methods. Evidence: Programmatic assessment is a systematic assessment approach that is gaining momentum across health professions education. Programmatic assessment, and in particular assessment for learning, is well-suited to address the challenges with clinical reasoning assessment. Several key principles of programmatic assessment are particularly well-aligned with developing a system to assess clinical reasoning: longitudinality, triangulation, use of a mix of assessment methods, proportionality, implementation of intermediate evaluations/reviews with faculty coaches, use of assessment for feedback, and increase in learners' agency. Repeated exposure and measurement are critical to develop a clinical reasoning assessment narrative, thus the assessment approach should optimally be longitudinal, providing multiple opportunities for growth and development. Triangulation provides a lens to assess the multidimensionality and contextuality of clinical reasoning and that of its different, yet related components, using a mix of different assessment methods. Proportionality ensures the richness of information on which to draw conclusions is commensurate with the stakes of the decision. Coaching facilitates the development of a feedback culture and allows to assess growth over time, while enhancing learners' agency. Implications: A programmatic assessment model of clinical reasoning that is developmentally oriented, optimizes learning though feedback and coaching, uses multiple assessment methods, and provides opportunity for meaningful triangulation of data can help address some of the challenges of clinical reasoning assessment.

The concept of professional resistance describes the principles professionals should follow when they seek to counter social harm and injustice. Applied to medical education, the principles of professional resistance can help learners and teachers balance the responsibilities to respond to harm and injustice with their roles and responsibilities as health professionals. However, there remains the problem of how educators and leaders can constructively respond to learner acts of resistance. It would seem that many leaders have dismissed learner resistance with variations on "Those Darn Kids!", a complaint that has long been levied at those in younger generations who challenge power and authority. How can productive change in medical education be achieved if learners' complaints are not taken seriously? Rather than dismissal, leaders and educators in these situations need the tools to engage learners in conversations that draw out their concerns.

Phenomenon: Most medical schools in Indonesia have developed innovations to integrate public health content into the curricula. However, ensuring that all schools meet appropriate standards regarding the quality of subjects, content relevancy, and course delivery takes time and effort. Approach: This study employed a rapid assessment procedure to identify the current knowledge and competencies required to practice medicine effectively in underserved, border, and outer island areas of Indonesia. Ninety-three participants from six remote districts were involved in 12 focus group discussions. Qualitative data were analyzed using content analysis using the social determinants of health as a guiding framework. Findings: Under decentralized health system governance, the local socio-geographical context is critical to understanding the current public health landscape. Medical education with respect to public health must emphasize physicians' ability to advocate and encourage the coordination of healthcare services in responding to disasters, as well as community-based surveillance and other relevant data for synergistic disease control. As part of a healthcare facility management team, prospective doctors should be able to apply systems thinking and provide critical input to improve service delivery at local health facilities. Also, recognizing underlying factors is essential to realizing effective interprofessional collaboration practices and aligning them with leadership skills. Insights: This study outlines recommendations for medical schools and relevant colleges in formulating compulsory block or integrated public health curricula. It also provides a public health learning topic that may aid medical schools in training their students to be competent for practice in underserved, border, and outer island areas. Medical schools should offer initiatives for students to acquire the necessary public health competencies merited by the population's health needs.

Phenomenon: While professionalism is largely understood to be complex and dynamic, it is oftentimes implemented as if it were static and concrete. As a result, policies and practices reflect dominant historical norms of the medical profession, which can cause tension for trainees from marginalized groups. One such group comprises those who identify as first-generation physicians - those whose parents have not earned an associate's degree or higher. This group is highly diverse in terms of gender, race, ethnicity, and socioeconomic status; however, their experiences with institutional professionalism policies and practices has not yet been fully explored. In this study, our aims were to understand the ways in which these participants experience professionalism, and to inform how professionalism can be more inclusively conceptualized. Approach: In November 2022-March 2023, we conducted semi-structured interviews with 11 first-generation medical students, residents, and physicians and analyzed select national and institutional professionalism policies in relation to key themes identified in the interviews. The interviews were designed to elicit participants' experiences with professionalism and where they experienced tension and challenges because of their first-gen identity. Data were analyzed using thematic analysis through a critical perspective, focused on identifying tensions because of systemic and historical factors. Findings: Participants described the ways in which they experienced tension between what was written, enacted, desirable, and possible around the following elements of professionalism: physical appearance; attendance and leaves of absence; and patient care. They described a deep connection to patient care but that this joy is often overshadowed by other elements of professionalism as well as healthcare system barriers. They also shared the ways in which they wish to contribute to changing how their institutions conceptualize professionalism. Insights: Given their unique paths to and through medicine and their marginalized status in medicine, first-generation interviewees provided a necessary lens for viewing the concept of professionalism that has been largely absent in medicine. These findings contribute to our understanding of professionalism conceptually, but also practically. As professionalism evolves, it is important for institutions to translate professionalism's complexity into educational practice as well as to involve diverse voices in refining professionalism definitions and policies.