Realizing the vision of the Lancet Commission on Education of Health Professionals for the 21st Century: Transforming medical education through the Accelerating Change in Medical Education Consortium

Applying self-determination theory to stem medical schools' clinical teacher sustainability crisis

THE PROBLEM

Medical schools require highly skilled and committed clinical faculty to teach, assess, supervise and mentor students' clinical care. Medical education is facing a crisis in recruiting and sustaining these clinical teachers. Faced with multiple demands and responsibilities in fast-paced clinical environments, teachers may not have the time, resources or stamina to sustain these critical roles. Medical school leaders must commit to and provide structures and processes to attract, sustain and retain clinical teachers.

CONCEPTUAL FRAMEWORK

The authors use the lens of self-determination theory to frame approaches to support teacher sustainability. Self-determination theory describes sources of human motivation. The theory and its evidence base characterise three human psychological needs: autonomy, competence, and relatedness. This theory can bridge individual psychological and institutional leadership perspectives to help medical school leaders anticipate and respond to their clinical teachers' needs. The authors propose three practical steps: practices to advance employee-centredness, processes to align individual and institutional values, and restructuring education to support clinical teachers' needs alongside student and patient needs. The authors describe limitations to this relational approach that focuses on leadership actions and consider individual agency as another key factor for sustainability.

DISCUSSION

Medical school leaders can develop and apply theory-driven approaches to advance sustainability. Sustainability now and in the future requires careful attention to the needs of clinical teachers and to their relationships with and within medical schools.

Global "systemness" in medical education: A rationale and framework to assess performance

Healthcare is global. The challenges of the "triple aim" - achieving high-quality healthcare, maximal value, and an excellent patient experience and outcomes - are universal. Medical education is similarly global with worldwide efforts towards competency-based reform, the adoption and adaptation of accreditation standards, and the expansion of international collaborations between healthcare organizations (HCOs). The focus of many of these efforts centers around recognizing education as a talent pipeline to serve local and global healthcare needs. Accordingly, many U.S.-based academic medical centres are pursuing an increasingly global footprint by developing international partnerships between HCOs. The educational leadership at the Cleveland Clinic (an HCO that has ventured internationally in Canada, the United Kingdom, and the United Arab Emirates) has adopted a "systemness" approach to medical education collaboratives. Systemness describes the ability of academic health systems to leverage existing structures, expertise, and other resources to address broadly shared educational needs across geographies, disseminate best practices, and ultimately improve the care that is delivered. The rationale for systemness, a concept derived from the healthcare administration and business world, affords the opportunity to achieve educational outcomes through synergy that exceeds the capability of any single component of a system. In this perspective, we posit a "systemness" taxonomy to be used to assess the performance and success of international collaborations in medical education and provide examples of its application to existing international partnerships in medical education. This framework is grounded in developmental assessment approaches, akin to those used in assessing learner performance, and defines levels of educational collaboration proficiencies, ultimately towards the alignment of these efforts with the health needs of the communities they serve. As global medical education collaboratives advance, ongoing assessment of existing partnerships and further research will be needed to define competencies and integrative activities that define high-performing medical education partnerships.

Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot

In 2014, the Association of American Medical Colleges (AAMC) published 13 Core Entrustable Professional Activities (EPAs) that graduating students should be able to perform with indirect supervision when entering residency. A ten-school multi-year pilot was commissioned to test feasibility of implementing training and assessment of the AAMC's 13 Core EPAs. In 2020-21, a case study was employed to describe pilot schools' implementation experiences. Teams from nine of ten schools were interviewed to identify means and contexts of implementing EPAs and lessons learned. Audiotapes were transcribed then coded by investigators using conventional content analysis and a constant comparative method. Coded passages were organized in a database and analyzed for themes. Consensus among school teams regarding facilitators of EPA implementation included team commitment to piloting EPAs; agreement that: proximal EPA adoption with curriculum reform facilitates EPA implementation; EPAs 'naturally fit' in clerkships and provided opportunity for schools to reflect on and adjust curricula and assessments; and inter-school collaboration bolstered individual school progress. Schools did not make high-stakes decisions about student progress (e.g., promotion, graduation), yet EPA assessment results complemented other forms of assessment in providing students with robust formative feedback about their progress. Teams had varied perceptions of school capability to implement an EPA framework, influenced by various levels of dean involvement, willingness, and capability of schools to invest in data systems and provide other resources, strategic deployment of EPAs and assessments, and faculty buy-in. These factors affected varied pace of implementation. Teams agreed on the worthiness of piloting the Core EPAs, but substantial work is still needed to fully employ an EPA framework at the scale of entire classes of students with enough assessments per EPA and with required data validity/reliability. Recommendations stemming from findings may help inform further implementation efforts across other schools adopting or considering an EPA framework.

Preparing learners to ACT as change agents: Early implementation of leadership curricula in dental education

OBJECTIVE

Graduates of dental schools are expected to become leaders in their practices, communities, and profession. Yet, formal leadership training is underutilized in U.S. dental school curricula to help learners develop these skills. The objective of this study was to understand third- and fourth-year dental students' perceptions of their initial semester of Bell Leadership Institute training as part of the novel Advocate, Clinician, Thinker curriculum at the UNC Adams School of Dentistry.

METHODS

Focus groups of 52 third- and fourth-year dental students were conducted after the completion of the first semester of leadership seminars. Session notes were transcribed, and qualitative analysis was performed to help elucidate student perceptions of the value and pertinence of the leadership seminars.

RESULTS

Participants valued the opportunities to self-reflect, develop listening skills, and learn strategies to address and mitigate conflict through the leadership seminars. Perceptions of seminar length, frequency, and structure were varied. Participants also noted that explicit connections and applications of leadership topics to the field of dentistry would improve the quality of the programing. Feedback from 52 focus group participants suggests a general appreciation for curriculum-integrated leadership training.

CONCLUSION

Early implementation of seminar-style leadership training in dental school curricula appears to be a productive avenue for developing critical leadership skills in dental school graduates.

Using a change management model to develop and implement dental curricula: A case study

Curriculum transformation is a guiding principle and driving force to continued institutional growth and innovation in oral health education. The transformation process starts from the need and desire for change to achieve the strategic goals of curriculum invocation. The design and implementation process must follow a systematic approach to ensure the oral health curricula are meeting the demands of preparing learners for their future careers and are in line with the institutional strategic goals and processes. The process of curriculum transformation needs to be carefully crafted and implemented to include all constituents and have clear and measurable outcomes to define its path and results. The University of North Carolina at Chapel Hill Adams School of Dentistry is undergoing the journey of oral health curriculum innovation and transformation. The goal of this paper is to describe the change management process using Kotter's organizational model that may apply to other schools aiming to innovate dental curricula.

Are Ethiopian schools of medicine producing competent medical graduates for providing quality health care in the era of COVID-19 pandemic?

BACKGROUND

Competent health workforce, including medical doctors, is the heart of health systems. Cognizant of this, Ethiopia is implementing licensure exam as a strategy to produce competent health workforce, including medical doctors and beyond, for the provision of high quality health care, among others. However, there is a dearth of evidence on medical graduates' competence in Ethiopia in the era of Covid-19 pandemic. Hence, this study aimed to assess the competence of medical graduates-based on licensure exam results in Ethiopia.

METHODS

A multi -center institution-based cross-sectional study was conducted among 1051 medical graduates (selected through cluster sampling method) from May - July 2022 in Medical Schools found in Amhara region, Northwest Ethiopia. Data were collected from secondary sources at the Ministry of Health and Medical Schools using a structured checklist. Data analysis was performed using SPSS Version 23 software. A binary logistic regression analysis was performed to identify factors associated with graduates' competence.

RESULTS

Nine hundred sixty-one (91.4%) medical graduates were competent. The study revealed that those graduates with older age (AOR: 0.63; 95% CI: 0.52, 0.76), being female graduates (AOR: 0.39; 95% CI: 0.22, 0.69), graduated in 2021 (AOR: 0.31; 95%; CI: 0.17, 0.60) and attending education in junior medical schools (AOR: 0.06; 95% CI : 0.01, 0.40) have lower competence as compared with that of their counterparts. Whereas, graduates with no repeating internship attachment (AOR: 2.41; 95% CI: 1.40, 4.17) and graduates with repeating academic year (AOR: 2.01; 95% CI: 1.14, 3.56) have better competence than that of their counterparts.

CONCLUSION

The proportion of competent medical graduates was relatively low as per the national strategic plan which aspires that all medical graduates to be competent. Medical graduate's competence was affected by age, gender, curriculum being implemented, and having academic as well as internship repeats. As result, policymakers should scale up competency based education in Medical Schools.

"Finding My Piece in That Puzzle": A Qualitative Study Exploring How Medical Students at Four U.S. Schools Envision Their Future Professional Identity in Relation to Health Systems

PURPOSE

Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation.

METHOD

Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives.

RESULTS

Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences).

CONCLUSIONS

This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.

We know but we hope: A qualitative study of the opinions and experiences on the inclusion of management, health economics and research in the medical curriculum

The achievement of global and national health goals requires a health workforce that is sufficient and trained. Despite considerable steps in medical education, the teaching of management, health economics and research skills for medical doctors are often neglected in medical curricula. This study explored the opinions and experiences of medical doctors and academic educationalists on the inclusion of management, health economics and research in the medical curriculum. A qualitative study was undertaken at four medical schools in Southern Africa (February to April 2021). The study population was medical doctors and academic educationalists. Semi-structured interviews with purposively sampled participants were conducted. All interviews were recorded and professionally transcribed. Constructivist grounded theory guided the analysis with the use of ATLAS.ti version 9.1.7.0 software. In total, 21 academic educationalists and 28 medical doctors were interviewed. In the first theme We know, participants acknowledged the constraints of medical schools but were adamant that management needed to be taught intentionally and explicitly. The teaching and assessment of management and health economics was generally reported to be ad hoc and unstructured. There was a desire that graduates are able to use, but not necessarily do research. In comparison to management and research, support for the inclusion of health economics in the curriculum was insignificant. Under We hope, educationalists hoped that the formal clinical teaching will somehow instil values and best practices of management and that medical doctors would become health advocates. Most participants wished that research training could be optimised, especially in relation to the duration of allocated time; the timing in the curriculum and the learning outcomes. Despite acknowledgement that management and research are topics that need to be taught, educationalists appeared to rely on chance to teach and assess management in particular. These qualitative study findings will be used to develop a discrete choice experiment to inform optimal curricula design.