Mistreatment and the learning environment for medical students on general surgery clerkship rotations: What do key stakeholders think?

New psychometric evidence for the thesis advisor abuse scale (EMAT) in Peruvian university students based on classic and modern procedures

Although evidence of mistreatment toward university students in the academic field has been reported for several years, its study in the context of the development of undergraduate research is still emerging. For this reason, it is necessary to have valid and reliable measurement instruments that allow assessing the magnitude of this problem. The objective of this study was to evaluate the psychometric properties of the Thesis Advisor Abuse Scale (EMAT, for its acronym in Spanish) in Peruvian university students. A total of 753 university students (women = 57.4%) from the 3 regions of Peru participated. The internal structure was analyzed under an analytical-factorial approach, and the discrimination and difficulty characteristics of the items were evaluated from the perspective of item response theory (IRT). The findings showed evidence supporting the original three-dimensional structure. Furthermore, all the items on the EMAT have good discriminatory power. Additionally, the EMAT proved to be strictly invariant according to sex, and the reliability coefficients reached high magnitudes. It is concluded that the EMAT is an instrument that has adequate psychometric properties to be used as a measure of mistreatment by advisors in the thesis preparation processes in Peruvian university students.

An assessment of surgery core rotation quality at osteopathic medical schools

CONTEXT

Osteopathic medical schools have traditionally placed a heavy emphasis on the field of primary care. While graduating osteopathic students continue to pursue family medicine, internal medicine, and pediatrics at higher rates than their allopathic counterparts, it is unknown whether students feel that surgical rotations are held to similar standards.

OBJECTIVES

The purpose of this study was to assess osteopathic medical student opinions of the quality of their surgical clerkships and to determine if good or poor experiences influenced their decision to continue pursuing surgery.

METHODS

After Institutional Review Board approval, a voluntary and anonymous Qualtrics survey was sent to all nationally registered members of the American College of Osteopathic Surgeons, Medical Student Section (ACOS-MSS) in their final 2 years of medical school. Analyses were conducted utilizing R statistical software.

RESULTS

A total of 345 responses were recorded from the Qualtrics survey sent to 2182 ACOS students from the national registry (response rate of 15.8 %). Students who found a mentor during their surgical rotations were more likely to consider a surgical career after they completed their rotations (odds ratio [OR]=1.43, p=0.003). Students at academic sites had more opportunities for research than those at community hospitals (p=0.019). Most students responded that they were still considering surgery as a career after rotation completion; a significant portion (OR=0.36, p<0.001) responded that they were no longer interested.

CONCLUSIONS

Medical students are most likely to review a surgical rotation favorably if they can connect with a mentor while on rotation. Osteopathic medical schools may benefit from instituting mentorship programs for students interested in surgery, as well as ensuring that their students have ample opportunity for research.

Neglect as an undefined and overlooked aspect of medical student mistreatment: A systematic review of the literature

PURPOSE

Although the mistreatment of medical students is a well-researched topic, the scope of mistreatment often leaves out neglect, a subtype for which there is no accepted definition based in the published literature. This review sought to summarize the existing data on the prevalence and descriptors of neglect, identify strategies seen in the literature designed to improve it, and offer a synthesized definition of this phenomenon to guide future research.

METHODS

Following PRISMA guidelines, a relevant systematic literature search from 2000 to April 2021 was performed to identify literature on neglect in clinical settings within American medical schools.

RESULTS

Neglect, a poorly defined phenomenon in medical education related to the suboptimal learning environment, is often excluded from research on medical student mistreatment. Neglect is a barrier to a successful learning environment, yet a paucity of data and the heterogeneous nature of the present literature render it difficult to estimate its true prevalence. Studies that include neglect frequently assess it solely as the result of identity discrimination or stated career interests. Recent interventions include promoting longitudinal relationships between students and clinical faculty and establishing teaching expectations.

CONCLUSIONS

Neglect is the mistreatment of medical students by the medical care team via a lack of meaningful inclusion in the clinical environment such that it has a notable negative impact on learning and student well-being, regardless of intentionality. An established definition that is grounded in the literature is required to create a common point of reference and understand its true prevalence, its associated variables, and the best mitigation strategies, as well as to guide future research, which should examine neglect independently and as a consequence of personal and professional identities.

Real-Time Student Feedback on the Surgical Learning Environment: Use of a Mobile Application

OBJECTIVE

Improvements to the medical student surgical learning environment are limited by lack of granular data and recall bias on end-of-clerkship evaluations. The purpose of this study was to identify specific areas for intervention using a novel real-time mobile application.

DESIGN

An application was designed to obtain real-time feedback from medical students regarding the learning environment on their surgical clerkship. Thematic analysis of student experiences was performed at the conclusion of 4 consecutive 12-week rotation blocks.

SETTING

Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.

RESULTS

Fifty-four medical students at a single institution were asked to participate during their primary clerkship experience. Students submitted 365 responses over 48 weeks. Multiple themes emerged which were dichotomized into positive and negative emotions centered on specific student priorities. Approximately half of responses were associated with positive emotions (52.9%) and half with negative emotions (47.1%). Student priorities included the desire to feel included in the surgical team (resulting in feeling engaged/ignored), to have a positive relationship with members of the team (perceiving kind/rude interactions), to witness compassionate patient care (observing empathy/disrespect for patients), to have a well-planned surgical rotation (experiencing organization/disorganization within teams), and to feel that student well-being is prioritized (reporting opportunities/disregard for student wellness).

CONCLUSION

A novel, user-friendly mobile application identified several areas to improve the experience and engagement of students on their surgery clerkship. Allowing clerkship directors and other educational leaders to collect longitudinal data in real time may allow for more targeted, timely improvements to the medical student surgical learning environment.

Fostering Authenticity in Surgical Education: Creating a Safe Space for Medical Students to Practice as Doctors

Over the past 10 years we have witnessed major changes to the medical education landscape in response to advances in digital technologies. Couple this with the disruptions imposed by the COVID-19 pandemic and we have what could be described as a 'perfect storm.' Rather than hunker down and wait for it to pass, we took it as an opportunity to re-evaluate how we practice surgical education in the fourth year of our 6 year medical programme. In this article, we describe the formation of 6 core principles that function as pivot points in developing a new perspective centered on the importance of engaging and empowering our students as emerging clinicians. From these 6 principles, we designed and developed 3 interventions. Each intervention is discussed in regard to its purpose, operation and overall integration into the program.

Incivility in medical education: a scoping review

Incivility in the workplace, school and political system in the United States has permeated mass and social media in recent years and has also been recognized as a detrimental factor in medical education. In this scoping review, we use the term incivility to encompass a spectrum of behaviors that occur across the continuum of medical education, and which include verbal abuse including rude or dismissive conduct, sexual and racial harassment and discrimination, and sexual and physical assault. We identified research on incivility involving medical students, residents and fellows, and faculty in North America to describe multiple aspects of incivility in medical education settings published since 2000. Our results reinforce that incivility is likely under-reported across the continuum of medical education and also confirmed incidences of incivility involving nursing personnel and patients, not emphasized in previous reviews. The authors suggest a zero-tolerance national policy if this problem is to be resolved.

Prevalence and Impact of Academic Violence in Medical Education

Situations of mistreatment in the academic environment are prevalent worldwide, but research in this area is scarce in middle-low-income countries. This study aimed to estimate the prevalence of mistreatment inflicted against Brazilian medical students. In addition, characterize these situations and analyze their consequences. Cross-sectional study conducted with 831 medical students from public and private institutions. Absolute and relative frequencies of the analyzed variables and possible associations were determined through univariate and multivariate logistic regression. Chi-square test of association with second-order Rao-Scott adjustment was also used. The response rate was 56%. Public institution pointed to a higher prevalence of mistreatment when compared to private (59% versus 43%). Female students were the most affected. Verbal and psychological aggression was more prevalent. The aggressor usually was a faculty member. Mistreatment incidence increased over the years of training, with higher rates in the internship. About 94% of the students felt affected in anyway, with 77% feeling diminished and depressed. More than 50% reported impaired academic performance. Almost 30% sought help from experts. The reporting rate was extremely low. Adequate identification of the situations by the victims, safe reporting mechanisms and, an educational system capable of maintaining an appropriate learning environment are essential to break this destructive cycle.

Improving the Obstetrics and Gynecology Learning Environment Through Faculty Development

INTRODUCTION

The learning environment is shaped by both formal and hidden curricula. Faculty play a critical role in the learning environment but may not be prepared to address the hidden curriculum. This workshop teaches faculty how to manage the hidden curriculum's challenges.

METHODS

Medical students' end-of-clerkship evaluations revealed low ratings in the domains of feedback, respectful interactions, professional language use, and empathy. We created a virtual 60-minute case-based faculty development workshop to highlight the role of faculty in improving the learning environment. A preworkshop survey was emailed to participants. At the workshop, following a brief introduction, participants were divided into groups to discuss the cases and develop strategies to improve the learning environment. A postworkshop survey was used to assess the workshop.

RESULTS

Sixty faculty members attended the seminar. Fifty-seven percent completed a preworkshop survey, and 33% completed the postworkshop survey. After the workshop, more faculty felt well prepared to engage students and residents. The majority of participants (85%) reported being more aware of issues around the learning environment. Most (85%) felt that their interactions with medical students would change in a positive way after the workshop. Ninety percent agreed the workshop was relevant to their needs, 70% agreed they learned a new skill in the workshop, and 80% committed to creating an inclusive learning environment after the workshop.

DISCUSSION

This workshop was well received by participants and was associated with an improvement in learning environment ratings. Faculty development seminars are an efficient tool to improve the learning environment.

Away Rotations at Integrated Thoracic Surgery Programs: Applicant and Program Director Perspectives

OBJECTIVE

Integrated thoracic surgery residency program (IP) applicants often complete away rotations to stand out from the objective standard criteria. Little is known about the perceptions of these rotations. We aimed to examine the perceptions of value, cost, and expectations of away rotations among IP applicants and program directors.

DESIGN

Between March and April 2020, anonymous electronic surveys were distributed through e-mails gathered from the Electronic Residency Application Service and the Accreditation Council for Graduate Medical Education IP email list. A follow-up email was sent to all applicants and program directors 1 week after the initial request to improve response rate. Questions assessed the cost, frequency, goals, and objectives for away rotations, as well as the perceived value of these experiences.

SETTING

United States PARTICIPANTS: All IP program directors and United States senior medical students who applied to our institution's IP during the 2019-2020 cycle.

RESULTS

Seventy-eight US medical students participated in the 2020 IP Match with 65 applicants applying to our institution's IP. Thirty-three responses were obtained from applicants who applied to our program (51% response rate). Survey responses were obtained from 8 program directors (31% response rate). Ninety-four percent of applicant respondents completed an IP away rotation (n = 31). Fifty-seven percent of these applicants spent on average $5000 in total for away rotations (n = 19). Overall, applicants felt that away rotations helped refine their perception of program location, educational and operative experience, treatment of medical students, and collegiality. Applicants and program directors acknowledged that creating a good impression and finding a compatible program were central values for participating in away rotations. However, program directors viewed the overall strength of the applicant as the most important factor when evaluating applicants. Fifty-five percent of applicant respondents matched at an IP (n = 17) with 35% matching at an IP where they had completed an away rotation (n = 6).

CONCLUSION

Extended interactions that can help create good impressions and establish compatibility are benefits to away rotations. However, given the current application conditions imposed by the pandemic, future studies should examine the impact of no away rotations on the IP Match process so that moving forward applicants and program directors can continue to weigh benefits to the costs and logistics of completing an away rotation.

A Novel Educational Tool to Improve Medical Student Knowledge Acquisition During Surgical Rotations

BACKGROUND

The addition of a novel education tool helps students improve understanding of general surgery topics. However, the effect of the new tool on objective exam performance is unknown.

MATERIALS

A 10-item card of high-yield general surgery topics was implemented in the third-year surgery clerkship. Students reviewed these topics with general surgery residents. Scores from the National Board of Medical Examiners (NBME) surgery subject exam and Step 2 Clinical Knowledge (CK) board exam were compared among students who completed the Ask-a-Resident Topic card to a control group.

RESULTS

Students who participated in the curriculum demonstrated significantly better scores on the NBME Surgery exam, t (236) = -2.56, P = .006. There was not a significant effect of the curriculum on Step 2 CK scores, although students who participated in the curriculum (M = 250.7, SD = 13.4) achieved higher scores than the control group (M = 247.8, SD = 14.2).

DISCUSSION

The novel curriculum may improve objective student performance on standardized surgery exams.

Incidence of resident mistreatment in the learning environment across three institutions

INTRODUCTION

Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment.

METHODS

Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences.

RESULTS

Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior.

CONCLUSION

Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.

Comparison of the Perspectives of Medical Students and Residents on the Surgery Learning Environment

BACKGROUND

The learning environment plays a critical role in learners' satisfaction and outcomes. However, we often lack insight into learners' perceptions and assessments of these environments. It can be difficult to discern learners' expectations, making their input critical. When medical students and surgery residents are asked to evaluate their teachers, what do they focus on?

MATERIALS AND METHODS

Open-ended comments from medical students' evaluations of residents and attending surgeons and from residents' evaluations of attendings during the 2016-2017 academic year were analyzed. Content analysis was used, and codes derived from the data. A matrix of theme by learner role was created to distinguish differences between medical student and resident learners. Subthemes were grouped based on similarity into high-order themes.

RESULTS

Two overarching themes were Creating a positive environment for learning by modeling professional behaviors and Intentionally engaging learners in training and educational opportunities. Medical students and residents made similar comments for the subthemes of appropriate demeanor, tone and dialog, respect, effective direct instruction, feedback, debriefing, giving appropriate levels of autonomy, and their expectations as team members on a service. Differences existed in the subthemes of punctuality, using evidence, clinical knowledge, efficiency, direct interactions with patients, learning outcomes, and career decisions.

CONCLUSIONS

Faculty development efforts should target professional communication, execution of teaching skills, and relationships among surgeons, other providers, and patients. Attendings should make efforts to discuss their approach to clinical decision making and patient interactions and help residents and medical students voice their opinions and questions through trusting adult learner-teacher relationships.

Enhancing Medical Student Education and Combating Mistreatment During a Surgery Clerkship With a Novel Educational Tool: A Pilot Study

BACKGROUND

Medical education changes dramatically from preclinical to clinical years, and the learning environment becomes key as students strive to develop clinical competence and informed career decisions. This change becomes heightened on a surgical clerkship where student mistreatment is often perceived, and the fast-paced nature of surgery can result in limited resident-student interactions and time for examination preparation.

OBJECTIVE

To evaluate medical student and resident perception of educational strategies during a surgical clerkship and to determine whether the addition of a novel educational tool would increase satisfaction with the surgical clerkship on examination preparation and team dynamics.

SETTING

University of North Carolina at Chapel Hill, Department of Surgery.

STUDY DESIGN

During the 2018-2019 academic year, a 10-item "Ask a Resident Topics" (ART) card of high yield general surgery topics was implemented as part of the third-year surgery clerkship curriculum. Students were asked to review a topic and then discuss it with a general surgery resident. They were expected to complete at least 6 of 10 topics by the end of the rotation for credit. At the end of the year, third-year medical students were administered a 23-item survey regarding their experience on the surgery clerkship and with the ART cards. Fourth-year medical students and those students at satellite sites who did not receive the ART cards were administered the same survey, minus specific questions about the ART card, and were used as a preintervention control. General surgery residents who participated in teaching were similarly surveyed.

RESULTS

Of those students that completed the ART cards, 84% felt it improved their understanding of general surgery and were more likely to report the surgery clerkship prepared them well for the NBME examination compared to those who did not (Χ² (1, N = 87) = 4.95, p = 0.03). They were also more likely to report residents were willing to discuss surgery topics with them (Χ² (1, N = 87) = 2.77, p = 0.10). Seventy-three percent of students thought the card did not add undue stress to their clerkship. Sixty-three percent of all students felt they were a productive member of the surgery team, and this did not vary by intervention group (Χ² (1, N = 87) = 0.03, p = 0.9). Students who completed the ART card were more likely to report being interested in surgery than those who did not (Χ² (1, N = 87) = 4.20, p = 0.04). Hundred percent of residents surveyed felt the ART card provided value for themselves as a teacher and for the student as a learner.

CONCLUSIONS

The ART card is mutually beneficial to both residents and medical students during the surgical clerkship. This tool is easy to implement, helps students improve their understanding of general surgery, increases camaraderie among the surgical team, and has a positive impact on students pursuing a career in surgery.

The "Invisible Student": Neglect as a Form of Medical Student Mistreatment, a Call to Action

The mistreatment of trainees is known to lead to burnout, loss of empathy, and career changes. Medical students in particular are vulnerable to mistreatment due to their lack of seniority and frequent transitions to new teams. Traditionally, initiatives to eliminate medical student mistreatment have focused on preventing their victimization surrounding verbal, physical, and sexual misconduct. While initiatives to eliminate these types of behaviors are exceedingly important, the most common form of mistreatment that is reported by medical students is not these active forms of abuse. Instead, students on their clinical rotations more frequently report the covert "obstruction of learning" or "exclusion from the medical team" as the most common form of mistreatment experienced. Though the passive neglect of a medical student is not seemingly as serious an offense as active abuse, it can certainly have an impactful, lasting negative effect on student development, morale, and career choice. In this perspective, we recognize the importance of observational learning as a component of medical education, but state that the neglect or exclusion of a medical student should not be considered acceptable and should be labeled what it is-a form of mistreatment. We additionally provide examples for how to prevent medical student neglect by establishing a supportive and inclusive teaching environment.

Difficulties Faced by General Surgery Residents. A Qualitative Systematic Review

BACKGROUND

General surgery residency training is academically rigorous, taxing and involves complex operative procedures. These trainings are synonymous with alarming burnout rates, high incidence of mistreatment reports and lower job satisfaction. Moreover, the established association between residents' levels of well-being and their capacity for empathy and patient care, emphasises the urgency to mitigate the negative connotations relating to surgical training. This systematic review aims to circumnavigate the multitude of problems faced by general surgical residents in training.

STUDY DESIGN

Literature searches were conducted on electronic databases Medline, PsycINFO, Embase, CINAHL, and Web of Science Core Collection using specific search criteria. Studies that analyzed the difficulties faced by General Surgery residents were eligible for inclusion Qualitative analysis involved the derivation of analytical themes and grouping data extracted from the papers accordingly.

RESULTS

After review of the full study texts, 19 studies met the inclusion criteria. The 3 main analytical themes identified were Problems regarding the Residency Programme, Work Associated Challenges, and Personal Concerns. Problems Regarding Residency Training was associated with residents' lack of experience. Work Associated Challenges highlighted problems with peer interactions, autocratic relationships, and communication with patients. Personal Concerns includes work-life balance, personal well-being and gender biases.

CONCLUSION

This systematic review delves into several prevalent difficulties that general surgical residents face, ranging from work related issues to personal difficulties. The results of this review can be used to provide complementary supportive measures for general surgical residents.

A Conceptual Model for Residents as Teachers in Obstetrics and Gynecology

BACKGROUND

The learning environment in obstetrics and gynecology (OB/GYN) may have intrinsic differences that require modifying existing resident as teacher models for high-quality teaching.

OBJECTIVE

To explore medical students' views of resident teaching on the OB/GYN clerkship in order to develop more effective educators.

METHODS

Between October 2017 and June 2018, we performed medical student focus groups at the end of the 2-month OB/GYN clerkship. Topics discussed included positive and negative teaching interactions with residents, barriers specific to the OB/GYN clerkship, and best methods for resident teaching. Qualitative analysis utilizing 3 reviewers and N-Vivo software were used to identify themes.

RESULTS

A total of 37 students participated in five focus groups. The most common barriers were a learning environment that was less predictable than on other rotations and lack of autonomy due to patient advocacy concerns. The three main contributors to positive learning experiences were team inclusion, clear expectations, and feedback. Negative interactions were passive learning experiences and inconsistent expectations. The best methods for resident teaching were verbalization of cognitive processes, preparation to use common patient encounters as teaching moments, and modeling skills needed for proficient patient care.

DISCUSSION

The learning environment on OB/GYN is unpredictable and influenced by four Ps: patient autonomy, passive experiences, procedures, and preconceived notions. The strategy of a resident teacher should focus on medical student inclusion and preparation for teaching role. We thus suggest a TEAM (Thinking Aloud, Expectations, Advanced Preparation, Modeling) approach to improve resident teaching on the OB/GYN clerkship.

Overcoming a Hostile Work and Learning Environment in Academic Surgery-Tools for Change at Every Level

Mistreatment has been documented as a negative factor in the learning environment for the past 30 y but little progress has been made to determine an effective way to significantly improve these interactions. Faculty may also be victims of a hostile work environment as well, although frequency has not been well-measured or reported. In fact, it may be difficult to identify and address mistreatment and hostility in the work place within the commonly established surgical culture. Thus, efforts to define, identify, and address workplace mistreatment or hostility are crucial to the success of the academic surgical environment. This article summarizes presentations and panel discussion that took place at the 2019 Academic Surgical Congress organized by the Association for Academic Surgery and the Society of University Surgeons. Definitions of mistreatment and hostility were provided, as well as information regarding occurrence. Tools for addressing mistreatment in the work environment and tips for creating a positive environment were presented and discussed.

Evaluation of a Preceptorship Model on Third-Year General Surgery Clerkship

BACKGROUND

Medical students increasingly report not feeling meaningfully involved during surgical clerkships. Preceptorship and mentorship through longitudinal experiences ameliorate this problem. A preceptorship model was introduced into the surgery clerkship at our institution to increase contact and improve relationships between students and faculty.

METHODS

The preceptorship model was introduced at select sites in 2017. In contrast to the standard structure in which students are assigned to cases and clinics as needed, preceptorship students are assigned to attending surgeons and follow the surgeons' schedules for the rotation. Student performance data, including final grades, clinical evaluations, and shelf examination scores, were collected for clerkship students from May 2017 to November 2018. Formative and summative evaluations for each student were collected. Qualitative content analysis was used to explore evaluations for themes.

RESULTS

Two hundred and seventy-four students completed the clerkship during the study period; 41 experienced a preceptorship model. There was no difference in student performance across clerkship structures. Summative and formative evaluations for preceptorship students were longer than for traditional students (137 words vs 78 words; p < 0.0001 and 46 words vs 16 words, p = 0.03 respectively). Preceptorship student evaluations contained higher-quality feedback relating to clerkship objectives than those of traditional students. Preceptorship comments also contained more frequent mentions of response to feedback.

CONCLUSIONS

A preceptorship model was successfully implemented on the third-year surgical clerkship at our institution. Although there was no difference between top performers on either clerkship structure, preceptorship students received written evaluations with better feedback as a result of their direct relationship with faculty. Strategies such as this, which improve student-faculty relationships, will be needed as programs find new ways to assess residency applicants.

More Than Aligning Perception: Impact of an Educational Intervention on Medical Student Mistreatment Reporting

BACKGROUND

Despite decades of reporting, rates of medical student mistreatment on the surgical clerkship remains a national issue. To understand whether misaligned perceptions about what constitutes mistreatment were leading to the high rates of reported mistreatment at our institution, we implemented an intervention designed to educate students about the unique challenges of the surgical environment and to build consensus around the definition of mistreatment.

STUDY DESIGN

Medical students were recruited from the surgery clerkship to participate in a video vignette-based curriculum accompanied by a facilitated discussion. Participants completed a survey before and after the educational intervention to assess their understanding of mistreatment and their perceptions of the surgical learning environment. At the end of each clerkship block students who participated in the intervention, as well as students who did not participate, were asked to complete a questionnaire about their experiences during the clerkship.

RESULTS

During 6 clerkship blocks, 53 students participated in the intervention (51% of the third-year student cohort). Students who participated in the intervention were more likely to report experiencing mistreatment or witnessing mistreatment during the clerkship. Students who participated in the intervention also reported experiencing neglect more frequently than students who did not participate.

CONCLUSIONS

We found that using an educational intervention designed to align perceptions of what constitutes mistreatment in the surgical learning environment did not decrease rates of mistreatment reporting on the surgical clerkship at our institution. Students who participated in the intervention reported increased confidence in their ability to define and recognize mistreatment after the intervention, as well as increased comfort reporting mistreatment and turning to faculty with concerns about mistreatment.

An Empirical National Assessment of the Learning Environment and Factors Associated With Program Culture

OBJECTIVES

To empirically describe surgical residency program culture and assess program characteristics associated with program culture.

SUMMARY BACKGROUND DATA

Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture.

METHODS

Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed.

RESULTS

Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics.

CONCLUSIONS

Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.

The Learning Environment in Surgery Clerkship: What are Faculty Perceptions?

OBJECTIVE

Multiple efforts have sought to improve teaching effectiveness and the learning environment (LE), but prior research has not focused on attending physicians' perceptions of mistreatment or contribution to the LE. The purpose of this study was to assess the perception and role of surgical faculty in the medical student LE.

DESIGN

A semistructured interview guide was developed using a comprehensive approach including extensive literature search and focus groups. Data were audio-recorded and transcribed verbatim. Content analysis was used to identify emergent themes.

SETTING

Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts.

PARTICIPANTS

Fifteen faculty in the Department of Surgery underwent detailed interviews. Participants were selected using purposive-stratified criterion-based sampling.

RESULTS

Multiple themes emerged: (1) The competing demands on medical student's time are a negative factor in the LE; (2) Faculty expectations conflict with the existing curriculum; (3) Faculty are concerned with the possibility of being reported for providing negative feedback; (4) Faculty remain unfamiliar with policies regarding the LE/mistreatment; (5) A motivated medical student makes the educational interaction more productive independent of specialty of choice.

CONCLUSIONS

Faculty identified that the most important factors contributing to a negative LE were a mismatch between expectations of medical students and faculty, and the conflict between the current curriculum and the faculty member's perceived ideal educational framework. Importantly, faculties were largely unfamiliar with LE/mistreatment policies and standards. These findings suggest a need for targeted curricula for faculty to raise awareness of components of a positive LE and tools to teach effectively within the contemporary medical school curriculum.

Identifying Medical Student Mistreatment in the Obstetrics and Gynecology Clerkship

OBJECTIVE

To characterize the mistreatment identified within the University of Michigan's Obstetrics and Gynecology (Ob/Gyn) clerkship and compare the rates of mistreatment to that of other clerkships in an effort to improve the learning environment.

DESIGN

This is a retrospective cohort study looking at multiple sources of data from 2015 to 2018 about student mistreatment including end-of-rotation and teaching evaluations completed by students, as well as an online reporting system available to medical students. For evaluations, students were asked to rate their agreement with statements on a 5-point Likert scale (1 = strongly disagree, to 5 = strongly agree). Narrative comments were also solicited and evaluated.

SETTING

University of Michigan Medical School and Michigan Medicine Ob/Gyn Department, Ann Arbor, Michigan.

PARTICIPANTS

A total of 513 students rotated through the Ob/Gyn clerkship between 2015 and 2018 and were asked to complete evaluations.

RESULTS

Five hundred and five of the 513 students completed evaluations between 2015 and 2018. In response to the statement, "Students are treated in a professional/respectful manner in this clerkship," the Ob/Gyn clerkship's mean scores on a 5-point scale were 4.45 (in 2015-2016), 4.52 (in 2016-2017), and 4.27 (in 2017-2018). These means, as well as the means to 3 other professionalism questions, were lower than the range of 4.42 to 4.84 for all other third-year clerkships over this time. The mean scores were also lower for Ob/gyn when compared to the Surgery clerkship. A total of 32 narrative comments were submitted by students between 2015 and 2017 related to mistreatment or unprofessional behavior. Frequent themes included students being treated as "stupid" or discouraged from asking questions (8 comments), being treated in an unprofessional manner by staff (7 comments), feeling ignored or marginalized by faculty (4 comments), and faculty unprofessional behavior toward others (4 comments).

CONCLUSIONS

Students on the Ob/Gyn clerkship reported a higher rate of mistreatment compared to other clerkships. Efforts are being made by the Ob/Gyn department to communicate these data on mistreatment to educators in order to improve the Ob/Gyn culture and learning environment for medical students.

To the point: undergraduate medical education learner mistreatment issues on the learning environment in the United States

This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is an overview of issues to consider regarding learner mistreatment and its effects on the undergraduate medical education learning environment in the United States. National data from the American Association of Medical Colleges Graduate Questionnaire and local data regarding learner mistreatment provide evidence that the learning environment at most medical schools needs to be improved. The American Association of Medical Colleges' definition of learner mistreatment focuses on active mistreatment, but data on passive mistreatment also contribute to a negative learning environment. The lack of tolerance for active mistreatment issues such as public humiliation and sexual and racial harassment need to be made transparent through institutional and departmental policies. Additionally, reporting mechanisms at both levels need to be created and acted upon. Passive mistreatment issues such as unclear expectations and neglect can also be addressed at institutional and departmental levels through training modules and appropriate communication loops to address these concerns. To fully confront and solve this challenging issue regarding learner mistreatment at the undergraduate medical education level, solutions to need to be implemented for faculty, residents, and students in the institutional, departmental, and clerkship settings.

Intraoperative Disruptive Behavior: The Medical Student's Perspective

OBJECTIVE

Intraoperative disruptive behavior can reduce psychological safety and hinder teamwork and communication. Medical students may provide unique insights into how to prevent these adverse impacts. We sought to characterize medical student perspectives on the causes and consequences of intraoperative disruptive behavior and ideal intraoperative working environments.

DESIGN

In this retrospective qualitative analysis, authors coded de-identified field notes from residency interviews to identify themes and key insights and to explore gender differences in perspectives.

SETTING

A tertiary academic medical training center in the Midwestern United States.

PARTICIPANTS

Forty-two medical students applying for urology residency placement.

RESULTS

Students were 57% male with an average age of 26 years (range 23-34). Most students witnessed intraoperative disruptive behavior (usually by surgeons) such as yelling, throwing instruments, or blaming others. Students described frustration with missing instruments and incompetent assistants as the most common instigators of disruptive behavior. They noted undesirable effects of disruptive behavior, including decreased communication/teamwork, lack of learning, increased technical mistakes, and recalled feeling afraid and stressed by these situations. They described ideal intraoperative working environments as calm, efficient and collaborative environments where questioning and learning is encouraged.

CONCLUSIONS

Students provide a valuable perspective on the causes and consequences of disruptive behavior during surgery and point to potential pathways to improvement. Their experiences suggest prevention or reduction of surgeon frustration might be a fruitful target for intervention efforts to prevent intraoperative disruption.

Beyond mistreatment: Learner neglect in the clinical teaching environment

Medical student mistreatment has been recognized as a deterrent to education as it interferes with the learning process and contributes to student burnout and attrition. Medical schools and leaders in undergraduate medical education have expended tremendous effort in addressing this phenomenon in hopes of eradicating mistreatment. However, there is a spectrum of behaviors that negatively impact the learning environment beyond that which is considered frank mistreatment. In this conceptual article, the authors propose the concept of learner neglect for the consideration by educators and researchers. This is a term for a range of behaviors exhibited intentionally or unintentionally by a supervisor that prevent a learner from reaching his or her potential. While the behaviors may overlap with mistreatment, they do not always fit within the definition of mistreatment. This concept is illustrated in the context of optimal and suboptimal teaching behaviors that commonly occur within the ecosystem of clinical education. Descriptions and examples are provided for both intentional and unintentional learner neglect. The authors hypothesize possible short- and long-term impacts of learner neglect, describe contributors to its prevalence, and offer questions for key stakeholders to consider in an effort to recognize, study, and ameliorate this issue within medical education programs.

Mistreatment and the Learning Environment: A Mixed Methods Approach to Assess Knowledge and Raise Awareness Amongst Residents

OBJECTIVE

Trainee mistreatment, either intentional or unintentional, negatively affects the learning environment. This study was undertaken to evaluate the impact of an educational intervention about mistreatment and the learning environment on general surgery residents.

DESIGN

Video-based modules were developed and added to the residency curriculum. Modules provided definitions and examples of active and passive mistreatment and components of positive and negative learning environments. A mixed-methods approach was used to assess the impact of this intervention. Residents completed a previously validated pre and post-test of related knowledge and attitudes (Abuse Sensitivity Questionnaire). Wilcoxon Signed Rank test was used to compare test results. During video-review sessions, discussion was prompted amongst residents using a semistructured interview guide. Immersion crystallization method was used to identify dominant themes.

SETTING

Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts.

PARTICIPANTS

All general surgery residents in our institution (n = 58) were invited to complete a survey at 3 time points.

RESULTS

Fifty-eight residents (55% male) responded to the survey (100% response rate). Mean age was 30.2 year (SD 3.9). Perception of nicknames related to personal identifiers (p = 0.0065) and name-calling (p = 0.02) changed significantly postintervention (Table 1). Regarding standards of behavior, 42 (72.4%) residents considered yelling not to be abusive unless it occurred frequently or constantly; 15 (25.8%) residents considered swearing (not directed at a person) as "not abuse"; 6 (10.3%) considered constructive criticism to be abusive if it was frequent or constant; and 24 (41%) residents feel powerless to intervene in these scenarios. Multiple themes emerged regarding resident-student interactions: (1) resident perception that description of behavior as mistreatment depends on medical student sensitivity; (2) neglect of medical students avoids trouble (e.g., being labeled as active mistreatment); (3) failure to integrate students into the surgical team may occur due to perceived lack of student interest; and (4) communication with the medical student is key. Residents reported that discussion along with video review was more effective than video review alone.

CONCLUSIONS

The video-based curriculum on mistreatment and the learning environment created awareness amongst residents about this important topic. Knowledge and attitudes about mistreatment changed in some areas postintervention. These findings suggest a need for development of complementary curricula to improve resident awareness and understanding of components of a positive learning environment and definition/examples of mistreatment.

Gamifying anatomy education

The objective of our research is to find out if gamification increases motivation for self-directed learning (SDL) of human anatomy among year 1 medical students, and more importantly, their academic grades (n = 120). At the NUS Yong Loo Lin School of Medicine, anatomy teaching has traditionally been delivered via didactic means. To encourage more active learning, suitable games (non-digital) and the script concordance test were utilized to enhance the process. The flipped classroom approach was also introduced to further trigger active learning. In addition, the use of mobile apps (digital) was also initiated as supplements for SDL. Feedback was collected based on the previously validated PRO-SDL scale. Results from the research yielded inconclusive evidence to support enhanced motivation among our students due to gamification (P > 0.05). However, it did help to encourage active participation for a "fun learning" experience supported by numerous positive comments. More importantly, the participant's continuous assessment (CA1, CA2, and CA3) and objective specific practical exam results were better than the cohort's average (P < 0.05), suggesting that enhanced meta-cognition, and factual recall had taken place. While it is positive, there are some caveats to note with gamification, first and foremost, that it is tutor dependent. Taken together, gamification could represent a new paradigm for anatomy education, and also an opportune time to change the prevailing culture in the healthcare and education industry. Clin. Anat. 31:997-1005, 2018. © 2018 Wiley Periodicals, Inc.

Interventions Designed to Improve the Learning Environment in the Health Professions: A Scoping Review

This article was migrated. The article was marked as recommended. Purpose: To identify and describe interventions designed to affect the learning environment (LE) in health professions education, summarize factors that influence the LE, and determine gaps that require additional research. The LE can be thought of as a dynamic and complex construct co-created by people in a particular setting. A positive LE represents a welcoming climate for learning, which enhances satisfaction, well-being, academic performance and collaboration, while a negative LE restricts participation and learning, leading to emotional exhaustion, depersonalization and burnout. Method: A six-step scoping review methodology was followed to identify and report on literature that describes interventions affecting the LE in the health professions education: 1. Identify the research question, 2. Identify relevant studies, 3. Select studies to be included, 4. Chart the data, 5. Collate, summarize and report results, and 6. Consult with stakeholders. Results: 2,201 unique citations were identified and reviewed using titles and abstracts. 240 full-text articles were retained for detailed review, resulting in the inclusion of 68 articles. Study results are reported in relation to essential components of the LE: personal, social, organizational, physical and virtual spaces. Results of four different types to the studies of the LE are described: specific interventionsimpacting the LE, comparisonsof perceptions of the LE by two or more different groups, associations with other variable such as well-being with the LE, and descriptivestudies of the LE. Major influences included accreditation regulations, curricular interventions, faculty/staff development grading practices, instructional interventions, placements, physical and virtual spaces, and support services; and are reported along with specific interventions. Conclusion: These results reflect the complexity of the LE and the need for conceptual clarity. Since the quality of the evidence was not evaluated, the identified influences should be viewed as potential opportunities to improve the LE.

Underlying mechanisms of mistreatment in the surgical learning environment: A thematic analysis of medical student perceptions

BACKGROUND

Medical students experience more psychological distress than the general population. One contributing factor is mistreatment. This study aims to understand the mechanisms of mistreatment as perceived by medical students.

METHODS

Students completed anonymous surveys during the first and last didactic session of their surgery clerkship in which they defined and gave examples of mistreatment. Team-based thematic analysis was performed on responses.

RESULTS

Between January 2014 and June 2016, 240 students participated in the surgery clerkship. Eighty-nine percent of students completed a survey. Themes observed included (1) Obstruction of Students' Learning, (2) Exploitation of Student Vulnerability, (3) Exclusion from the Medical Team, and (4) Contextual Amplifiers of Mistreatment Severity.

CONCLUSION

The themes observed in this study improve our understanding of the students' perspective on mistreatment as it relates to their role in the clinical learning context, which can serve as a starting point for interventions that ultimately improve students' experiences in the clinical setting.