The Hidden Curricula of Medical Education: A Scoping Review

Comparison of Online Peer-Assisted Learning and Faculty-Led Teaching for Short Answer Questions

INTRODUCTION

Peer-assisted learning (PAL) is a well-recognised pedagogical approach in medical education; however, research on its effectiveness in online settings remains limited. Multiple-choice questions have been the predominant method for assessing PAL outcomes, despite Short Answer Questions (SAQs) being the superior tool for evaluating knowledge. This study compares online peer and faculty teaching in enhancing medical students' higher-order thinking skills and assesses students' perceptions of these methods.

METHODS

Third-year medical students undergoing surgical placements were consented and recruited for the study. Three pre-defined cohorts were randomised to the following arms: no intervention (n = 41), online PAL teaching (n = 37) and online faculty teaching (n = 35). Peer teaching was delivered by fourth-year students (n = 6) and faculty teaching by Clinical Teaching Fellows (CTFs) (n = 6). Academic outcomes were assessed using end-of-block SAQ formatives, and teaching quality was evaluated using the validated SEEQ questionnaire. Knowledge gain and self-perceived confidence were assessed through pre- and post-session tests, validated with a reference group of learners.

RESULTS

Consent for SAQ exam scores was obtained from n = 19 (no intervention), n = 29 (PAL) and n = 21 (CTF). No significant differences were seen between the groups (p = 0.650). SEEQ completion was n = 24 (PAL) and n = 30 (CTF). CTF tutors received significantly higher ratings in domains of Learning (p = 0.017) and Group Interaction (p = 0.036). Pre- and post-session tests showed no significant differences in scores (p = 0.957) or self-perceived confidence ratings (p = 0.454).

CONCLUSION

This study shows that online PAL is a viable alternative to faculty-led teaching for enhancing SAQ skills and knowledge acquisition. However, faculty-led teaching offers a superior educational experience.

Too close for comfort: Intergenerational blame and disillusionment in social work supervision in the West Bank, Palestine

Palestinian social work is taking form in the West Bank in the context of Israel's increasingly violent and restrictive multigenerational occupation, with limited relevant theory and research to guide practice. Social work students in Palestine, as elsewhere, learn to practice under the supervision of experienced social workers in clinics, hospitals, schools, and other agencies. Supervision becomes a key setting for the hidden curriculum-teaching and learning that is not officially recognized. We aimed to study training supervision in Palestine as a window on the moral organizing of the profession. Using modified grounded theory methods, we interviewed and followed 99 supervisors and 14 undergraduate students over a two-year period in 12 West Bank cities. Our analysis reveals an intergenerational clash of values between supervisors and students. Unable to adequately respond to the acuity of need, supervisors and students blame each other for feelings of helplessness and complacency in the normalization of the occupation. Learning to work with each other, in spite of and through disappointment, is central to their training. This relationship can also provide a foundation for creative clinical activism. The curriculum is not just unspoken, but actively kept hidden, as students learn both implicitly and explicitly to protect their feelings and the details of their work as a means of forbearance and agency in the setting of precarity and disillusionment. The hidden curriculum, or the curriculum in hiding, operates as an affectively charged site of moral contestation, central to the emergence of the profession under prolonged occupation.

"I get to relate to my patients": Latinx medical students and residents' navigational capital in medical education

While the U.S. Latinx population has rapidly increased in the past 30 years, the number of Latinx physicians has not kept pace. Latinx students are often motivated to pursue medicine to serve those in their communities, which benefits Latinx community health outcomes through patient-clinician cultural and linguistic concordance. However, significant barriers often prevent Latinx people from successfully navigating the transition to and through medical school. This study utilized a qualitative, constructivist approach to investigate the transition to and through medical school and residency to further understand and prevent leakages for aspiring Latinx physicians. Using an assets-based framework of Community Cultural Wealth (CCW), we specifically explored navigational capital, to understand how Latinx learners navigate belonging in medicine. Through semi-structured interviews with 20 Latinx medical students and 14 residents, we found that learners understood and created belonging by navigating help-seeking and the imposter phenomenon through their respective pathways in medicine. Findings from this study may be used to develop support systems and resources to reduce the structural inequalities, barriers, and challenges Latinx students and future physicians encounter through medical education pathways.

Accounts of women from Asian ethnic backgrounds about their medical undergraduate experiences in the UK - an interpretative phenomenological study

BACKGROUND

Asian ethnic women face discrimination within UK medical schools. Their experiences, shaped by intersecting identities, demand focused attention and understanding. This study aims to explore their experiences, especially on understanding how the intersecting identities shape their educational journeys.

METHODS

An interpretative phenomenological analysis (IPA) approach was used to explore lived experiences and perceptions of five fourth-year medical students from one institution. Transcripts from semi-structured interviews were analysed following IPA procedures, with an emphasis on understanding the intersectionality of gender and ethnicity in shaping experiences.

RESULTS

Analysis of the transcripts produced four overarching themes with six subthemes. The four themes were: discriminatory action, impact, reaction to the action and expectations and solutions. 'Discriminatory action' highlights the direct and indirect discrimination that the students faced. Students' personal sense of identity shaped the 'impact' theme whilst perseverance, tolerance and acceptance of discrimination defined the 'reaction' theme. The 'expectations and solutions' theme reflects how students anticipate change and propose solutions to mitigate these issues. Participants strongly urged institutions to take more proactive steps in addressing these concerns.

CONCLUSION

Discrimination significantly impacts the wellbeing and education of Asian women medical students. These challenges have implications for career progression and contribute to broader inequities in medicine. We recommend medical schools consider including a curriculum to address these concerns as a priority in the early years of the medical degree.

Neurogastroenterology: The Cinderella among the ecological niches of gastroenterology?

Neurogastroenterology (NGE) refers to a specific sub-specialty of gastroenterology that investigates the pathophysiology, diagnostics and therapeutic approaches to the "disorders of gut-brain interaction" (DGBIs), frequently encountered in clinical practice and often associated with poor quality of life and high healthcare costs. Two recent national surveys, focused on common DGBIs, highlighted two main issues. Despite the high incidence of DGBIs there is a lack of awareness and appropriate training to effectively treat these conditions and a lack of specific referral centers in each region. Indeed, specific training and a multidisciplinary approach are required to properly manage these patients, but these are not always available. As a result, NGE lacks attractiveness for many young gastroenterologists. We believe that NGE has great potential to emerge among the various sub-branches of gastroenterology. However, its growth is limited by lack of specific training, knowledge, accessibility, diagnostic capabilities, multidisciplinary integration, and financial investments in research. To bridge this gap, it would be helpful to overcome these limits through an increase in specific training concerning DGBIs among students, residents, physicians and general practitioners. This, coupled with improved access to advanced diagnostic tests, innovative therapies, and a better multidisciplinary approach, could help expand the knowledge in this still niche area and achieve better treatment outcomes for patients.

Creating Health Professions Trainee-Heroes Through Transformative Learning

In this #MedEd commentary, @jameswykow & @VipsMDMEd discuss opposing sides of the same coin: #TransformativeLearning and the #HiddenCurriculum

A Small Group Interview Evaluating the Impact of a Widening Access Programme on Student Confidence and Their Medical School Applications

Background

In the United Kingdom, individuals from deprived backgrounds are under-represented in the medical workforce. Widening participation seeks to address the barriers they face. This study examined Lancashire Access Medics: a widening participation programme in the North-West of England led by junior doctors and medical students for Year 12 and Year 13 pupils.

Materials and Methods

The programme used an outcome-based curriculum with regular online group and individual sessions to support pupils. The programme was supported by a local medical school's widening participation team. A small group interview was conducted, using thematic analysis, to explore the experiences of the pupils on the programme.

Results

Positive findings include the continuous pastoral support, supportive learning environment, and overall session structure, which contributed to pupils developing key skills ideal for medical school applicants. The support with personal statement development and interview preparation was commended. However, participants requested more support with their aptitude tests and expressed a preference for in-person sessions.

Conclusion

The programme provides a low-cost model for widening participation, which can reach high-priority areas and can be replicated by other groups. Widening participation initiatives should consider the use of an outcome-based curriculum, with sound session design and opportunities for addressing individual pupil needs. Whilst the virtual learning environment may make such work more feasible to deliver, pupils may find it more difficult to engage compared to being in-person.

Empowerment of Learners through Curriculum Co-Creation: Practical Implications of a Radical Educational Theory

Framing the Issue: Medical education programs in the U.S. rely on the aphorism that faculty own the curriculum; that is, the specialized knowledge, skills, and attitudes of a physician are the province of the faculty to be delivered to tuition-paying students. From this view, the learner's role is one of passivity and deference. A contrasting approach, termed curriculum co-creation, frames education as a bi-lateral partnership. Co-creation results from learners, in collaboration with instructors, taking an active role in creating the goals and processes of an educational program. Such a partnership requires substantial revision of the expectations for both learners and instructors. In this Observations article, the idea of co-creation is applied to medical education and an aspirational vision for the role and value of faculty-student co-creation is advocated. Description and Explication: Co-creation partnerships of faculty and students occur in many forms, varying in degree of departure from traditional educational practice. Co-creation principles and partnerships can be deployed for almost all aspects of training including selection and organization of content, effective methods of instruction, and assessment of student learning. The outcomes of co-creation occur at three levels. The most specific outcome of co-creation is characterized by increased student engagement and enhanced learning. Broader outcomes include improved efficacy and value in the educational program and institution while, at the farthest-reaching level, a co-creative process can modify the medical profession itself. Although some specific instructional techniques to promote student involvement and input have historically been deployed in medical education, there is little evidence that students have ever been permitted to share in ownership. Implications for Medical Education: When fully embraced, curricular co-creation will be recognizable through improved student engagement and learning along with a revised understanding of how faculty-student relationships can foment reform in medical education and the culture of the profession. Further scholarship and research will be indispensable to examine how co-creative partnerships can flatten hierarchies within medical education and inspire the medical profession to be more inclusive and effective. Following the model of co-creation is expected to inspire learners by empowering them to participate fully as co-owners of their own education and prepare them to lead medical education in a different direction for the future.

Preparing for exclusion: The hidden curriculum of success in medical student guidebooks

Despite decades of diversification efforts, U.S. medical school matriculants remain predominantly white, wealthy, and able-bodied, with fewer than 25% from under-represented minority backgrounds. While medical school application guidebooks claim to democratize access by demystifying the competitive admissions process, our content analysis of 38 such guides reveals how they paradoxically reinforce existing barriers to entry. Our examination shows how these guidebooks, in making admissions processes more transparent and explicit, simultaneously transmit subtle and implicit forms of professional gatekeeping that define who belongs-and importantly, who doesn't belong-in medicine. Specifically, we find that the guidebooks, which were designed to initiate "naïve" non-professionals into the profession's expectations, collectively described the ideal applicant and physician as someone implicitly wealthy, white, male, and able-bodied. Through both their inclusions and omissions, the guidebooks illuminated the "right" reasons for entering medicine and who was well-suited for, and worthy of, the profession, thereby delineating who belonged and who did not. This investigation makes two key contributions to medical education literature: it demonstrates how guidebooks function as tools of early professional socialization, establishing a hidden curriculum before formal training begins, and shows how this curriculum perpetuates external social closure, complementing research on discriminatory norms and internal social closure in medicine. We conclude with a call for the critical re-evaluation of pre-professional messaging to achieve better inclusivity in medicine.

The influence of the hidden curriculum on the risk of burnout in junior doctors in a palliative medicine rotation - a qualitative exploratory study

BACKGROUND

Palliative Care (PC) provides person-centred care for patients with life-limiting diseases and their families. Studies have shown that healthcare professionals delivering PC are predisposed to moral distress and burnout due to constant exposure to death and dying and aspects of the hidden curriculum (HC) through which culture and values are transmitted implicitly. However, there are limited studies focusing on the latter through the lens of junior doctors. Using the Ring Theory of Personhood (RToP) and the Krishna-Pisupati Model (KPM), which categorize and map conflicts between personal and professional values, beliefs, and principles within the four domains of personhood, this study investigates the impact of palliative care experiences on the risk of burnout in junior doctors.

METHODS

This qualitative exploratory study was conducted at the Division of Supportive and Palliative Care in the National Cancer Centre Singapore, involving medical residents who had completed at least one month with the division between 2020 and 2022. 13 participants were recruited for individual semi-structured interviews carried out by an independent research assistant. Acknowledging HC and burnout as sociocultural constructs, we adopted a constructivist ontological position and a relativist epistemological lens to guide thematic analysis of the data.

RESULTS

The themes identified were: (1) The Nature of PC (2), Moral Distress, and (3) Impact of Environment on Wellbeing. Junior doctors saw the value of the philosophy of care in PC and felt compelled to adopt values espoused by the discipline. However, compounded by consistent exposure to death and dying and limitations to manpower and time, elements of the HC, such as staff support measures, proved to be significant stressors-contributing to burnout and moral distress.

CONCLUSION

This is the first study on the effects of the HC on burnout for junior doctors in a PC rotation. It provides unique insights into the impact of complex clinical, personal, social, ethical and organizational factors on burnout and suggests that all factors need to be addressed in tandem for any attempts at staff support to be successful. This study can guide current and future research and programs that support wellbeing for junior doctors.

Teaching Knowledge and Empathy in Substance Use Disorder Through Enriched Education in the Neurobiology of Addiction: A Narrative Review on Addiction Education in Professional Schools

BACKGROUND

Addiction is a devastating chronic disease requiring significant resources and attention. Healthcare professionals have noted struggles in caring for patients with substance use disorder (SUD) due to stigma, perceived difficulties in dealing with patients, and issues with treatment compliance. Challenges in dealing with individuals with SUD may stem from an inadequate understanding of the disease and consequent misconceptions about patient behaviors. The type and extent of addiction education affect the depth of understanding of SUD and shape attitudes toward patients. In this review, we explore aspects of addiction education including examining curricular guidelines and educational strategies, especially regarding the neurobiology of addiction.

METHODS

We conducted a narrative review using online databases and search engines to identify studies related to addiction/SUD education with emphasis on the type and extent of neurobiological content.

RESULTS

Studies examining addiction education document deficiencies that may contribute to insufficiencies in SUD treatment and disrespectful treatment of individuals with SUD. There is also a lack of detail regarding the extent of the neurobiology of addiction education in professional core courses and curricular guidelines. Implementing a more detailed approach to addiction education with more comprehensive neurobiology is discussed along with strategies to motivate students to learn and appreciate these complex details.

CONCLUSIONS

While there are many aspects of addiction education, a solid foundation in the neurobiological mechanisms of addiction is important to establish an appreciation for the disease nature of addiction and the resulting behaviors of the individual. Teaching beyond the rewarding nature of addiction is essential to enable students to comprehend how the activation of survival stress systems and compromised decision-making affects the behavior of individuals with SUD. A more comprehensive understanding of addiction fosters more respect for individuals with SUD and creates potential for more opportunities for effective treatment.

The Hidden Curriculum in Which Medical Students Learn to Understand and Manage Unprofessional Behaviour: A Qualitative Interview Study

Objectives

Medical students frequently experience unprofessional behaviours (e.g. incivility, bullying), adversely impacting personal and professional development. Formal reporting is rare, suggesting students manage unprofessional behaviour through alternate means. This study investigated the role of a hidden curriculum in medical students' understanding and management of unprofessional behaviours in medical education.

Design

Third-year medical students were recruited from an Australian medical school. Semi-structured interviews were conducted, and thematic analysis was performed to identify themes in how unprofessional behaviour is experienced and managed.

Results

All 17 participants had experienced unprofessional behaviour, and most had witnessed it directed at others. Only two participants reported these experiences. Four themes were identified. (1) Students rationalised whether an incident was reportable based on severity of unprofessional behaviour, and adjusted their personal standards. (2) They described perpetrator power and position as barriers to reporting, where senior staff committing unprofessional behaviour held sway over students' medical education. (3) This contributed to perceptions of the fallibility of reporting, that it carried a high risk of negative consequences, with unclear or no reward. (4) In the importance of debriefing, students preferred to manage unprofessional behaviour through informal peer discussions to make sense of their experiences, avoid future encounters, and collectively better understand the culture of medicine.

Conclusions

A hidden curriculum was identified whereby students learn to understand and respond to unprofessional behaviour based on their experiences at medical school. The culture of tolerance of unprofessional behaviour and silence in medicine must be addressed if change is to occur.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02208-4.

The bias algorithm: how AI in healthcare exacerbates ethnic and racial disparities - a scoping review

This scoping review examined racial and ethnic bias in artificial intelligence health algorithms (AIHA), the role of stakeholders in oversight, and the consequences of AIHA for health equity. Using the PRISMA-ScR guidelines, databases were searched between 2020 and 2024 using the terms racial and ethnic bias in health algorithms resulting in a final sample of 23 sources. Suggestions for how to mitigate algorithmic bias were compiled and evaluated, roles played by stakeholders were identified, and governance and stewardship plans for AIHA were examined. While AIHA represent a significant breakthrough in predictive analytics and treatment optimization, regularly outperforming humans in diagnostic precision and accuracy, they also present serious challenges to patient privacy, data security, institutional transparency, and health equity. Evidence from extant sources including those in this review showed that AIHA carry the potential to perpetuate health inequities. While the current study considered AIHA in the US, the use of AIHA carries implications for global health equity.

Implicit bias assessment by career stage in medical education training: a narrative review

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person based on individual characteristics. Early evaluation of implicit bias in medical training can prevent long-term adverse health outcomes related to racial bias. However, to our knowledge, no present studies examine the sequential assessment of implicit bias through the different stages of medical training. The objective of this narrative review is to examine the breadth of existing publications that assess implicit bias at the current levels of medical training, pre-medical, graduate, and postgraduate. Protocol for this study was drafted using the Scale for the Assessment of Narrative Reviews (SANRA). Keyword literature search on peer-reviewed databases Google Scholar, PubMed, Ebsco, ScienceDirect, and MedEd Portal from January 1, 2017, to March 1, 2022, was used to identify applicable research articles. The online database search identified 1,512 articles. Full screening resulted in 75 papers meeting the inclusion criteria. Over 50% of extracted papers (74%) were published between 2019 and 2021 and investigated implicit bias at the post-graduate level (43%), followed by the graduate level (34%), and pre-medical level (9.4%). Fourteen percent were classified as mixed. Studies at the medical and medical graduate level identified an implicit preference towards white, male, non-LGBTQIA+, thin, patients. Study findings highlight notable gaps within the sequential assessment of implicit bias, specifically at the pre-medical training level. Longitudinal epidemiological research is needed to examine the long-term effect of implicit biases on existing healthcare disparities.

Medical Students' Observations of High Value and Potentially Wasteful Care Behaviors Modeled During Clinical Rotations

BACKGROUND

Medical student exposure to role-modeling of high-value care (HVC) behaviors may shape professional identity formation and future HVC practices.

OBJECTIVE

To investigate the frequency and characteristics of HVC role-modeling witnessed by medical students during core clinical rotations.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

Medical students on clinical rotations at 11 US medical schools.

MAIN MEASURES

A validated 13-item survey was used to assess medical student perception of cost-conscious role-modeling behaviors or potentially wasteful role-modeling behaviors and modified to include whom demonstrated the behavior (attending vs resident/fellow) and during which clinical rotation the modeling occurred.

KEY RESULTS

Cost-conscious role-modeling behaviors were observed by medical students sometimes/often 52.9-70.5% (353/667-452/641) of the time across all clinical rotations, except for praising a student for ordering a cost-effective diagnostic work-up which was seen only 25.7% (143/556) of the time. Potentially wasteful role-modeling behaviors were observed sometimes/often 5-14.3% (26/537-87/609) of the time, except simultaneously ordering numerous tests before seeing results of initial screening tests 45.1% (273/605) and repeating tests rather than attempting to obtain recently performed test results 32.2% (194/602). HVC modeling was most often demonstrated by internal medicine attendings 67.7% (65/96) and least frequently by general surgery attendings 47.3% (17/36). Attendings were overall more likely to model HVC compared to residents/fellows.

CONCLUSION

HVC role-modeling, as observed by medical students, is not consistently demonstrated across clinical rotations. Attendings generally model more HVC than residents and general surgery models less HVC compared to other specialties. Future studies should strive to identify factors which promote or inhibit HVC modeling.

You cannot be what you cannot see: a retrospective natural longitudinal cohort study exploring the impact of face-to-face rural immersion on student medical training satisfaction and intention to practice rurally

OBJECTIVE

Community-engaged immersive rural experiences were limited during the COVID-19 pandemic when online learning was instigated across medical institutions globally. This study aimed to explore the impact of online learning on medical students' satisfaction levels and intentions to practice in a rural area after graduation.

DESIGN, SETTING AND PARTICIPANTS

We conducted a natural quasi-experimental longitudinal retrospective cross-sectional study during 2011-2022 for all Australian domestic medical students who undertook a Rural and Remote Medicine (RRM) placement at the University of Queensland. Anonymous administrative course evaluation data were collected for the same two questions in each cohort over 12 years, between 2011 and 2022.

OUTCOME MEASURES

Change in students' intention to pursue a rural medical career and teaching and placement satisfaction levels was determined. Longitudinal data illustrated trends in students' intention and overall satisfaction across cohorts before and during COVID-19 disruptions.

RESULTS

2695 students participated in the surveys with an average response rate of 81%. Intention levels remained steady between 2011 and 2019, during which students experienced a consistent face-to-face orientation and rural placement immersion. During the COVID-19 disruption phase, primarily in 2020 and 2021, students' intention to pursue a rural medical career significantly decreased when online-only learning placements were implemented, with only 25% of students in the most impacted rotation indicating a strong positive intention, compared with a previous steady 75%. Comparatively, students' satisfaction with the RRM programme remained steady across all the years at about 85-90%.

CONCLUSIONS

There appears to be a detrimental impact of a lack of immersive community-engaged education experiences on medical student's intention to pursue a rural medical career. This natural experiment demonstrates that while online learning maintains student satisfaction levels, it lacks value and authenticity and does not inspire students to consider future rural careers. The value of face-to-face and immersive community-engaged experiences is fundamentally an important contributor to inspiring students to work in rural areas in the future.

Paediatric patient perceptions of healthcare professionals: contributions to a communication curriculum

Communication skills are a vital but often neglected part of paediatric training. To make communication training more responsive to patient needs, children and adolescents should be involved in developing the communication curriculum for healthcare professionals, though this is rarely the case. The present study explored children and adolescents' perceptions of healthcare professionals to identify recommendations for healthcare professionals to contribute to formulating goals, learning objectives, and competencies for an interprofessional paediatric communication curriculum. We used narrative and play-based interviews to include the perceptions of preschool children aged 3-6 years (n = 8) and an online questionnaire to explore those of schoolchildren and adolescents aged 5-18 years (n = 54). We did a thematic analysis of the qualitative interview data and open-ended questionnaire responses, which showed that preschool children found familiar approaches, physical contact, and their parents comforting and that healthcare professionals should use playful methods, child-friendly words, and tangible rewards. Schoolchildren and adolescents preferred healthcare professionals who were friendly, patient, attentive, communicated clearly, and engaged them in conversation. They did not like when healthcare professionals appeared stressed, did not keep their promises, or forced them to do something.

CONCLUSIONS

We condensed perceptions of children and adolescents into tips and statements to be used in further development of a communication curriculum for paediatric healthcare professionals. Our findings emphasize that paediatric communication training should focus on healthcare professionals' attitude and appearance, strategies for building trust and engaging patients in treatment and care, the use of age-appropriate communication, and understanding the cognitive development of children and adolescents.

WHAT IS KNOWN

• Communication is a core competence that all paediatric healthcare professionals must practice and maintain. • Children and adolescents can contribute to curriculum development, but only few studies have done so.

WHAT IS NEW

• The perspectives of children and adolescents indicate that education programmes on paediatric communication should focus on the attitude and appearance of healthcare professionals, strategies to build trust and engage patients, age-appropriate communication, and understanding the cognitive development of children and adolescents. • Children and adolescents aged 3-18 years can contribute to the development of goals, learning objectives, and competencies for paediatric communication training, which may help promote more patient-centred approaches in practice.

Revisiting the conceptualisation and implications of medicine's 'hidden curriculum'

In medical training and practice, our professional attributes, attitudes, perceptions, character traits and identities are fundamentally shaped by our lived experiences and observations in clinical and para-clinical settings instead of being inculcated through formal curriculum or classroom teaching. For instance, clinical acumen, communication skills and bedside manners are learnt through role modelling and experiential learning in the course of clinical rotations. Likewise, one's attitudes, professional behaviours and inclinations are often also influenced by direct/indirect observations of the actions of others in the medical fraternity in various clinical and non-clinical settings. This is also what is often termed as the 'hidden curriculum' of medicine. In this article, we sought to provide a practical conceptualisation of the hidden curriculum in medical training, which we describe as lived experiences and personal observations of medical trainees and residents in clinical and para-clinical spaces, which shape their perceptions of the medical profession (vocational identity and purpose), patients (patient-physician relationship) and colleagues (intra- and inter-professional relationships), with downstream implications on physician well-being and clinical decision-making. Although this idea of a 'hidden curriculum' has conventionally carried predominantly negative connotations in medical literature, we suggest that it is an inevitable part of medical education and practice, which, through deliberate regulation, can potentially be shaped to create more positive and meaningful effects in the professional development of medical trainees.

Unlocking Medical Student Success: A Systematic Review and Meta-Analysis of Third-Party Resources Used for Medical Education and USMLE Board Preparation

An increase in third-party commercial resources targeted towards medical students has led to substantial changes in the way students prepare for medical assessments. A systematic review and meta-analysis was conducted to identify the third-party resources most used by medical students. A total of 1056 citations were screened with 19 full-text studies included. Twenty-two unique third-party resources were examined, with meta-analysis revealing the three most used resources to be First Aid, UWorld, and Pathoma. Medical faculty should consider curriculum adaptation to better cater to the learning needs of students and institute systems that ensure equitable access to verified commercial resources.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02116-7.

Tailoring neurosurgical operating room education to medical undergraduates: Integrative review and meta-synthesis

Introduction

Integrating medical students into the neurosurgical operating room (OR) presents significant pedagogical challenges, compounded by the phenomenon of neurophobia, or aversion to neuroscience. Despite the importance of early neurosurgical exposure, there is a lack of structured educational strategies for undergraduates.Research Question How can neurosurgical OR education be effectively tailored to address undergraduate medical students' educational needs and mitigate neurophobia?

Material and methods

This study employs an integrative approach, combining narrative synthesis and critical interpretive synthesis (CIS). A comprehensive literature review was conducted across databases such as PubMed, Scopus, and ERIC. Key themes and patterns were identified through iterative reading, coding, and thematic analysis. CIS was utilized to integrate these themes into a coherent theoretical framework, focusing on applicability, feasibility, and educational impact.

Results

The study presents twelve targeted strategies to optimize neurosurgical OR education. These include preoperative planning, fostering a positive learning environment, emphasizing technological integration, involving students in decision-making, prioritizing safety, providing regular feedback, facilitating active participation, leveraging teachable moments, managing time constraints, offering follow-up opportunities, emphasizing professionalism, and fostering a learning culture.

Discussion and conclusion

This framework addresses a critical gap in neurosurgical education for undergraduates, tackling neurophobia and enhancing learning experiences. By integrating educational theories with practical insights, it offers a robust, adaptable approach suitable for various global resource settings. Through continuous evaluation and refinement, these strategies can evolve to meet the dynamic demands of neurosurgical education, preparing students to navigate the complexities of modern neurosurgical practice with confidence and competence.

Assessing the hidden curriculum in medical education: a scoping review and residency program's reflection

Background

While the hidden curriculum (HC) is becoming recognized as an important component of medical education, ideal methods of assessing the HC are not well known. The aim of this study was to review the literature for methods of assessing the HC in the context of healthcare education.

Methods

We conducted a scoping review on methods to measure or assess the HC in accordance with the JBI Manual for Evidence Synthesis. Ovid MEDLINE, Ovid EMBASE, and ProQuest ERIC databases were searched from inception until August 2023. Studies which focused on healthcare education, including medicine, as well as other professions such as nursing, social work, pharmacy were included. We then obtained stakeholder feedback utilizing the results of this review to inform the ongoing HC assessment process within our own medical education program.

Results

Of 141 studies included for full text review, 41 were included for analysis and data extraction. Most studies were conducted in North America and qualitative in nature. Physician education was best represented with most studies set in undergraduate medical education (n = 21, 51%). Assessment techniques included interviews (n = 19, 46%), cross-sectional surveys (n = 14, 34%), written reflections (n = 7, 17%), and direct observation of the working environment (n = 2, 5%). While attempts to create standardized HC evaluation methods were identified, there were no examples of implementation into an educational program formally or longitudinally. No studies reported on actions taken based on evaluation results. Confidential stakeholder feedback was obtained from postgraduate medical learners in our program, and this feedback was then used to modify our longitudinal HC assessment process.

Conclusions

While the HC has as increasing presence in the medical education community, the ideal way to practically assess it within a healthcare education context remains unclear. We described the HC assessment process utilized at our program, which may be informative for other institutions attempting to implement a similar technique. Future attempts and studies would benefit from reporting longitudinal data and impacts of assessment results.

Novice clinician educator professional identity formation through a longitudinal mentorship: a qualitative study

BACKGROUND

The professional identity of doctors is evolving with physicians now required to be 'scholars', facilitating the education of students and healthcare teammates as educators. Mentoring is widely practiced and is postulated to facilitate professional identity formation (PIF) through socialization. Preliminary literature review suggested few studies looking into how formal mentoring programmes affect PIF of novice clinician educators, particularly an Asian context. I hope to understand the perceived professional identity of such educators, and what changes in professional identity are observed after longitudinal mentorship, using the social cognitive career theory (SCCT) as an underpinning framework.

METHODS

A qualitative study explored perspectives of mentees with less than two years teaching experience and participating in a formal mentoring programme. Semi-structured interviews were conducted at the beginning and end of the programme. Thematic analysis and coding of these taped and transcribed interviews was performed and triangulated with an elite interview. Mind maps were constructed to appreciate the inter-relatedness of themes and evaluated using the SCCT framework. Methodology was anchored to the Consolidated Criteria for Reporting Qualitative Research checklist.

RESULTS

Seven mentees were recruited. All were Chinese except for two Indians. All had less than six months experience with educational activities. None had formal training in medical education. Median duration postgraduate was six years. One was from a surgical discipline, others were from a range of medical disciplines. Themes identified included background influences, learning experiences and outcome expectations which affected self-efficacy, leading to mentees attaining goals and performing actions which effected their professional identity development, which was in-turn affected by contextual influences. Most perceived themselves as clinicians rather than medical educators. Concepts underpinning PIF included socialisation (role modelling and mentorship, communities of practice, sense of belonging), experiential learning, the hidden curriculum and reflective practice.

CONCLUSIONS

Novice clinician educators mostly have a hierarchical identity. Role modelling and mentorship, active participation in communities of practice, promotion of a sense-of-belonging, experiential learning combined with reflective practice are important components for socialisation, synergistically facilitating PIF in novice clinician educators. Overcoming contextual barriers, being cognisant of cultural practices and addressing concerns in the hidden curriculum can assist educators in development of their professional identity.

Finding Themselves, Their Place, Their Way: Uncertainties Identified by Medical Students

Phenomenon: Navigating uncertainty is a core skill when practicing medicine. Increasingly, the need to better prepare medical students for uncertainty has been recognized. Our current understanding of medical students' perspectives on uncertainty is primarily based on quantitative studies with limited qualitative research having been performed to date. We need to know from where and how sources of uncertainty can arise so that educators can better support medical students learning to respond to uncertainty. This research's aim was to describe the sources of uncertainty that medical students identify in their education. Approach: Informed by our previously published framework of clinical uncertainty, we designed and distributed a survey to second, fourth-, and sixth-year medical students at the University of Otago, Aotearoa New Zealand. Between February and May 2019, 716 medical students were invited to identify sources of uncertainty encountered in their education to date. We used reflexive thematic analysis to analyze responses. Findings: Four-hundred-sixty-five participants completed the survey (65% response rate). We identified three major sources of uncertainty: insecurities, role confusion, and navigating learning environments. Insecurities related to students' doubts about knowledge and capabilities, which were magnified by comparing themselves to peers. Role confusion impacted upon students' ability to learn, meet the expectations of others, and contribute to patient care. Navigating the educational, social, and cultural features of clinical and non-clinical learning environments resulted in uncertainty as students faced new environments, hierarchies, and identified challenges with speaking up. Insights: This study provides an in-depth understanding of the wide range of sources of medical students' uncertainties, encompassing how they see themselves, their roles, and their interactions with their learning environments. These results enhance our theoretical understanding of the complexity of uncertainty in medical education. Insights from this research can be applied by educators to better support students develop the skills to respond to a core element of medical practice.

Critical ethnography: implications for medical education research and scholarship

CONTEXT

Medical education (ME) must rethink the dominant culture's fundamental assumptions and unintended consequences on less advantaged groups and society at large. Doing so, however, requires a robust understanding of what we are teaching, regardless of our intentions, and what is being learned across the multiple settings that our learners find themselves in, from classrooms to clinical spaces and beyond.

APPROACH

Gaining such understandings and fully exploring the extent to which we are rising to the challenges of today's society in authentic ways require robust methodologies. In this research approaches paper, we introduce unfamiliar readers to one such methodology-critical ethnography. By doing so, we hope to demonstrate its potential for helping ME both identify and gain novel insight into necessary solutions for many of today's educational challenges regarding healthcare disparities and inequities.

CONCLUSION

The readers of this paper will gain novel insights into how critical ethnographers see the world and ask questions, thereby changing the way they (the reader) see the world. At its heart, critical ethnography is about thinking differently and that is something that should be accessible to all. Doing so may also enhance our ability to both question dominant ways of thinking and, ultimately, to enact positive change in training and practices to enhance inclusivity and fairness for all regardless of their gender, race and status.

Professionalism in Residency Training: The Learning Environment for Professionalism Survey

Role modelling is important in developing professionalism with a need for reliable, evidence-based tools to assess professionalism in the learning environment (LE). The Learning Environment for Professionalism (LEP) survey is brief, anonymous and balanced assessing medical trainees' and attendings' positive and negative professionalism behaviours that can be tracked longitudinally and identify problem areas in the LE. Seven training programs agreed to facilitate administration of the LEP survey at four hospitals in Ottawa, Canada. The survey was carried out iteratively between 2013 and 2020. A total of 3783 LE ratings of training programs and hospitals were assessed longitudinally using univariate linear regression. A Bonferroni corrected p-value of ≤.0045 was used to account for multiple comparisons. Positive professional behaviours were observed across time with some of the negative behaviors having improved. A negative signal was found, with attendings appearing to be treating patients unfairly because of their financial status, ethnic background, sexual or religious preferences. Applying LEP survey longitudinally across diverse training programs and institutions is feasible and may assist programs to identify areas requiring attention and acknowledging areas of exemplary professionalism. Continuous monitoring of LE to meet requirements of accrediting bodies can also be considered an important quality improvement metric.

Contraceptive counseling training experiences and behaviors among obstetrics and gynecology residents in California and Florida

OBJECTIVE

To describe experiences with contraception counseling training and provision of obstetrics and gynecology residents training in California and Florida.

STUDY DESIGN

We conducted a mixed-methods study of obstetrics and gynecology residents training across 19 programs (with approximately 428 residents) in California and Florida from September 2022 through February 2023. We asked participants how often they use tiered-effectiveness counseling, their satisfaction with contraception counseling practices, and experiences with witnessing and recognizing contraception coercion. We asked about personal disappointment when patients decline long-acting reversible contraception (LARC) and pressure from faculty to prescribe LARC. To further explore resident contraception counseling education and behaviors, we conducted semi-structured telephone interviews with a subset of 20 survey volunteers.

RESULTS

We received survey responses from 155 (36.2%) participants. Most (n = 113 [76.4%]) often or always reported using tiered-effectiveness counseling. While few participants (n = 17 [11.3%]) reported feeling pressure from faculty to convince a patient to keep a LARC, some (n = 34 [22.1%]) reported they often or always feel disappointed when a patient chooses LARC removal, with more Florida participants reporting disappointment (n = 19 [37.3%]) compared to California (n = 15 [14.6%], p = 0.01). We identified two main themes from the telephone interviews. First, residents feel they have limited formal education on how to provide contraceptive counseling and commonly learn these practices by emulating supervising faculty or peer counseling styles. Second, residents are informally taught, through feedback and interactions with supervising faculty and peers, that successful contraception counseling is the ability to convince patients to use highly effective contraception.

CONCLUSION

When residents lack formalized contraception counseling education, they adopt counseling behaviors that may not be patient centered.

IMPLICATIONS

When obstetrics and gynecology residents lack formalized contraception counseling education, they learn practices that may lead to coercive counseling behaviors during training. Resident education should include recognition and mitigation of contraception coercion and patient-centered counseling both through a formalized curriculum and socialization of trainees during their medical education.

Do educational interventions reduce the gender gap in communication skills?- a systematic review

BACKGROUND

Efficient doctor-patient communication is essential for improving patient care. The impact of educational interventions on the communication skills of male and female students has not been systematically reviewed. The aim of this review is to identify interventions used to improve communication skills in medical curricula and investigate their effectiveness in improving the communication skills of male and female medical students.

METHODS

A systematic review of the literature was conducted using the PRISMA guidelines. Inclusion criteria were as follows: used intervention strategies aiming to improve communication skills, participants were medical students, and studies were primary research studies, systematic reviews, or meta-analyses.

RESULTS

2913 articles were identified based on search terms. After title, abstract, and full-text review, 58 studies were included with interventions consisting of Training or Drama Courses, Curriculum-Integrated, Patient Learning Courses, and Community-Based Learning Courses. 69% of articles reported improved communication skills for both genders equally, 28% for women more than men, and 3% for men more than women. 16 of the 58 articles reported numerical data regarding communication skills pre-and post-intervention. Analysis revealed that post-intervention scores are significantly greater than pre-intervention scores for both male (p < 0.001) and female students (p < 0.001). While the post-test scores of male students were significantly lower than that of female students (p = 0.01), there is no significant difference between genders for the benefits, or difference between post-intervention and pre-intervention scores (p = 0.15), suggesting that both genders benefited equally.

CONCLUSION

Implementation of communication training into medical education leads to improvement in communication skills of medical students, irrespective of gender. No specific interventions benefitting male students have been identified from published literature, suggesting need of further studies to explore the phenomenon of gender gap in communication skills and how to minimize the differences between male and female students.

Certified Nurse-Midwives as Teachers: Expanding Interprofessional Collaboration Learning Opportunities for Medical Students on the Obstetrics and Gynecology Clerkship

INTRODUCTION

Interprofessional experiences provide critical exposure to collaborative health care teams, yet medical students often lack this experience during clinical clerkships. We created a labor and delivery triage rotation exclusively staffed by certified nurse-midwives in the obstetrics and gynecology clerkship to address this gap. We sought to evaluate the clinical learning experiences of medical students rotating on this midwife-supervised collaborative team.

METHODS

Between 2018 and 2020, we electronically sent all medical students an evaluation after each required clerkship. Our primary outcome was the quality of teaching score, as defined by level of agreement on a 5-point Likert scale with a statement regarding teaching quality. A secondary outcome evaluated scores from the National Board of Medical Examiners (NBME) Obstetrics and Gynecology subject examination taken by all students at the end of the rotation. Evaluations and assessments were compared between students rotating on labor and delivery triage and those who did not. Evaluation comments from students rotating on labor and delivery triage were collated to identify common themes.

RESULTS

Of 374 students, 370 (98.9%) completed the end-of-clerkship course evaluation and 312 (83.4%) completed teaching evaluations. Sixty-seven students (17.9%) rotated in labor and delivery triage; of these, 52 (77.6%) completed both the course and triage rotation evaluations. There were no differences in the mean quality of teaching scores (3.9 ± 1.2 versus 3.8 ± 1.2, p = 0.54) or in NBME Obstetrics and Gynecology subject examination scores between students rotating in labor and delivery triage compared to all other rotations (79.9% ± 7.2% vs 80.2% ± 7.8%, P = 0.436). Comments from teaching evaluations highlighted student exposure to the midwifery philosophy of care model.

DISCUSSION

This work demonstrates the feasibility and benefits of this midwife-led authentic interprofessional collaborative experience for medical students. This model can serve as an example of how to implement and evaluate interprofessional collaboration experiences in the clinical setting.

Development and psychometric evaluation of the hidden curriculum assessment scale in nursing education: A validity and reliability study

AIMS

The study aimed to develop and psychometrically evaluate a measurement scale for identifying and assessing the hidden curriculum in undergraduate nursing education.

BACKGROUND

The hidden curriculum is a general term for educational information that exists outside of the teaching program and mainly affects students' knowledge, emotions, behaviors, beliefs, values and professional ethics. However, a specific instrument to comprehensively define and assess the hidden curriculum in nursing education has not yet been developed in China.

DESIGN

A descriptive and explorative study design was used.

METHODS

We developed the initial scale through a literature review, focus group discussion, Delphi expert consultation and pre-survey. From February to April 2023, the data were collected from a convenient sample of 512 nursing students enrolled in five medical universities in China to conduct exploratory factor analysis and confirmatory factor analysis for validity testing. In addition, reliability analysis was conducted by calculating Cronbach's alpha coefficients, split-half reliability and test-retest reliability. The nursing students' responses were evaluated using a five-point Likert scale.

RESULTS

The Hidden Curriculum Assessment Scale in Nursing Education (HCAS-NE) was formulated, consisting of 4 dimensions and 35 items. Exploratory factor analysis extracted four factors, with a cumulative variance contribution rate of 66.863 % and confirmatory factor analysis indicated that the fit indices values of the scale structure model met the criteria for an ideal level. the Cronbach's α coefficient of the scale was 0.965, the Guttman split-half was 0.853 and the test-retest reliability was 0.967.

CONCLUSION

This study demonstrated that the Hidden Curriculum Assessment Scale in Nursing Education (HCAS-NE) has ideal reliability and validity, which provides a valid and reliable tool for identifying and assessing the hidden curriculum in nursing education.

Beyond empathy training for practitioners: Cultivating empathic healthcare systems and leadership

Empathic care benefits patients and practitioners, and empathy training for practitioners can enhance empathy. However, practitioners do not operate in a vacuum. For empathy to thrive, healthcare consultations must be situated in a nurturing milieu, guided by empathic, compassionate leaders. Empathy will be suppressed, or even reversed if practitioners are burned out and working in an unpleasant, under-resourced environment with increasingly poorly served and dissatisfied patients. Efforts to enhance empathy must therefore go beyond training practitioners to address system-level factors that foster empathy. These include patient education, cultivating empathic leadership, customer service training for reception staff, valuing cleaning and all ancillary staff, creating healing spaces, and using appropriate, efficiency saving technology to reduce the administrative burden on healthcare practitioners. We divide these elements into environmental factors, organisational factors, job factors, and individual characteristics.

The Schweitzer effect: The fundamental relationship between experience and medical students' opinions on professional behaviours

PURPOSE

We examined whether medical students' opinions on the acceptability of a behaviour were influenced by previously encountering a similar professionally challenging situation, assessed the magnitude of effect of 'experience' compared to other demographic factors which influence medical students' opinions, and evaluated whether opinions regarding some situations/behaviours were more susceptible to 'experience' bias?

METHODS

Confidential, on-line survey for medical students distributed to Australian and New Zealand (AUS/NZ) medical schools. Students submitted de-identified demographic information, provided opinions on the acceptability of a wide range of student behaviours in professionally challenging situations, and whether they had encountered similar situations.

RESULTS

3171 students participated from all 21 Aus/NZ medical schools (16% of registered students). Medical students reported encountering many of the professionally challenging situations, with varying opinions on what was acceptable behaviour. The most significant factor influencing acceptability towards a behaviour was whether the student reported encountering a similar situation. The professional dilemmas most significantly influenced by previous experience typically related to behaviours that students could witness in clinical environments, and often involved breaches of trust.

CONCLUSIONS

Our results demonstrate the relationship between experience and medical students' opinions on professional behaviour- the 'Schweitzer effect'. When students encounter poor examples of professional behaviour, especially concerning trust breaches, it significantly influences their perception of the behaviour. These results highlight the importance of placing students in healthcare settings with positive professional role modelling/work cultures.

The hidden curriculum across medical disciplines: an examination of scope, impact, and context

Background

While research suggests that manifestations of the hidden curriculum (HC) phenomenon have the potential to reinforce or undermine the values of an institution, very few studies have comprehensively measured its scope, impact, and the varied clinical teaching and learning contexts within which they occur. We explored the HC and examined the validity of newly developed constructs and determined the influence of context on the HC.

Methods

We surveyed medical students (n =182), residents (n =148), and faculty (n = 140) from all disciplines at our institution between 2019 and 2020. Based on prior research and expertise, we measured participants' experience with the HC including perceptions of respect and disrespect for different medical disciplines, settings in which the HC is experienced, impact of the HC, personal actions, efficacy, and their institutional perceptions. We examined the factor structure, reliability, and validity of the HC constructs using exploratory factor analysis Cronbach's alpha, regression analysis and Pearson's correlations.

Results

Expert judges (physician faculty and medical learners) confirmed the content validity of the items used and the analysis revealed new HC constructs reflecting negative expressions, positive impacts and expressions, negative impacts, personal actions, and positive institutional perceptions of the HC. Evidence for criterion validity was found for the negative impacts and the personal actions constructs and were significantly associated with the stage of respondents' career and gender. Support for convergent validity was obtained for HC constructs that were significantly correlated with certain contexts within which the HC occurs.

Conclusion

More unique dimensions and contexts of the HC exist than have been previously documented. The findings demonstrate that specific clinical contexts can be targeted to improve negative expressions and impacts of the HC.

The figured world of medical education senior leaders: Making meaning and enacting agency

INTRODUCTION

The field of medical education is relatively new, and its boundaries are not firmly established. If we had a better understanding of the intricacies of the domain, we might be better equipped to navigate the ever-changing demands we must address. To that end, we explore medical education as a world wherein leaders harness agency, improvisation, discourse, positionality and power to act.

METHODS

Using the constructivist theory of figured worlds (FW), we conducted a narrative analysis of the stories medical education senior leaders tell about their roles and experiences in the world of medical education (n = 9).

RESULTS

We identified four foundational premises about the world of medical education: (i) medical education stands at the intersection of three interrelated worlds of clinical medicine, hospital administration and university administration; (ii) medical education is shaped by and shapes the clinical learning environment at the local level; (iii) medical education experiences ubiquitous change which is a source of power; and (iv) medical education is energised by relationships between individuals.

DISCUSSION

Focusing on the FW theory's notions of agency, improvisation, discourse, positionality and power enabled us to describe the world of medical education as a complex domain existing in a space of conflicting power hierarchies, identities and discourses. Using FW allowed us to see the powerful affordances offered to medical education due to its position between worlds amid unceasing change.

Symbolic access: medical students' awareness of institutional culture and its influence on learning, a phenomenographic study

BACKGROUND

The discussion of access in medical education has its focus largely on physical and epistemological access, leaving a qualitative gap regarding sociocultural factors which enable access in this context. This study introduces and defines symbolic access, a concept with a specific lens on sociocultural inclusion, and the influence it has on student learning within the South African medical education landscape.

METHODS

A phenomenographic design was used to explore students' conceptions of symbolic access and its impact on learning. One-on-one exploratory interviews were conducted with fifteen final year medical students at the University of Witwatersrand in Johannesburg. Interviews were analysed using Sjöström and Dahlgren's seven-step phenomenography model.

RESULTS

Four categories of description were induced, which described students' understanding of symbolic access, these were rejection, disregard, invalidation, and actualization. Four dimensions of variation were discovered expressing the diversity of events which informed the collectives' understanding of the phenomenon. These dimensions were; interactions with educators, peer relationships, educational environment, and race. Categories of description and dimensions of variation formed the Outcome Space, a visual representation of the student experience of symbolic access. The outcome space had a double narrative related to symbolic access; exclusion (major) and actualization (minor). Medical student's chief experience within the medical community was exclusion, however clinical immersion, meaningful participation, peer-relationships, and clinical skills lessons facilitated community enculturation, and impacted learning.

CONCLUSION

Despite deeply exclusionary experiences throughout their programme, medical students articulated a paradox of both awareness and no awareness of symbolic access. The awareness of symbolic access was predominantly influenced by clinical experiences and clinical immersion during the pre-clinical and clinical years of study. Further, descriptions of valuable learning experiences were connected to clinical events and the involvement with patient care. This study suggests that the actualization of symbolic access and description of meaningful learning experiences are linked. Medical educationalists should design undergraduate curricula with early clinical immersion at the fore and explore symbolic concepts pertaining to access, as they are linked to transformative learning experiences for the medical student.

Medical students' attitude toward patient-centeredness: A longitudinal study

OBJECTIVES

This study explored the trajectories of patient-centered orientation in a sample of Italian medical students throughout medical school.

METHODS

Four consecutive student cohorts were longitudinally assessed at the second (T0) and fifth year (T1) of medical school. Students completed a questionnaire including demographics and the Italian validated version of the Patient-Practitioner Orientation Scale.

RESULTS

352 students completed both administrations. Students became more patient-centered in terms of Sharing along the course of their clinical curriculum, whereas there were no significant changes in Caring. Groups with distinct developmental trajectory patterns of both Caring and Sharing were identified. Students high in patient-centeredness at T0 reported significantly lower scores at T1 while students with lower scores at T0 significantly increased from the first to the last measurement. Female students significantly outscored their male colleagues on Caring and Sharing in both administrations.

CONCLUSIONS

Findings call for innovative education strategies to sustain patient-centeredness attitudes in medical students entering hospital-based clinical medicine. Further research is needed to identify characteristics of the medical curriculum that are primarily involved in fostering students' patient-centeredness.

PRACTICE IMPLICATIONS

Including the assessment and monitoring of patient-centeredness throughout the medical school can inform tailored education aiming to foster this dimension.

Teaching Sex- and Gender-Sensitive Medicine Is Not Just a Matter of Content

Despite a growing integration of sex and gender-sensitive content in medical education around the globe, the focus on content often leads to a lack of consideration of the hidden curriculum. To foster an inclusive, sex- and gender-sensitive culture in medical education, we have to take a holistic approach that transcends a sole focus on explicit teaching content. This article provides reflections about the practice of teaching sex and gender-sensitive medicine focusing on the impactful yet implicit notions we convey about sex and gender in medical education. We propose action for leaders and teachers in medical education to explicitly address sex/gender in the hidden curriculum and within their institution, challenging the invisible practices of academia in the medical field.

"The Water in Which We Swim:" A Unique, Post-Clerkship Multidisciplinary Course

OBJECTIVE

To improve patient outcomes and promote health equity, medical students must be taught not only biomedicine, but also the social sciences to understand the larger contexts in which patients live and health care operates. Yet, most undergraduate medical education does not explicitly cover these topics in a required, longitudinal curriculum.

METHODS

In January 2015 at Harvard Medical School, we created a two-part sequence (pre- and post-clerkship) of required, 4-week multidisciplinary courses-"Essentials of the Profession I and II"-to fill this gap. "Essentials of the Profession II (EOP2)" is an advanced social sciences course anchored in patient narratives and the lived experiences of students and includes clinical epidemiology and population health, healthcare delivery and leadership, health policy, medical ethics and professionalism, and social medicine that engages students to conduct structural analyses to be effective healers, advocates, and leaders.

RESULTS

Per student course evaluations, the overall course rating was 1.7 (SD 0.9, 1 = excellent and 5 = poor); its overall rating has improved over time; and it has scored well even when run virtually. It was rated highly in application of critical thinking, integration of the disciplines, and relevance for clinical work. Qualitative analyses of student responses revealed the following key course strengths: breadth of topics, teaching faculty and guest speakers, and small group discussions. The weaknesses included workload, lack of diversity of opinions, repetition, and time spent in lectures.

CONCLUSIONS

We argue that EOP2 is "essential" for post-clerkship medical education. It offers an opportunity to re-ignite and enhance humanism and activism; remind students why they chose the medical profession; equip them with frameworks and toolkits to help them to overcome challenges; and devise solutions to improve health care and patient outcomes that are applicable to their future training and ongoing practice of medicine.

Factors Affecting Medical Residents' Decisions to Work After Call

BACKGROUND

Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions (WHRs) are intended to improve patient safety by reducing resident fatigue. Compliance with ACGME WHRs is not universal.

PURPOSE

The purpose of this study was to identify factors that influence residents' decisions to take a postcall day (PCD) off according to ACGME WHRs.

METHODS

Residents (N = 433) at one university were emailed a link to a survey in 2019. The survey included demographic details and a Discrete Choice Experiment examining influences on resident decisions to take a PCD off.

RESULTS

One hundred seventy-five residents (40.4%) responded to the survey; 113 residents (26%) completed the survey. Positive feedback from attending physicians about taking PCDs off in the past had the greatest impact on respondents' decisions to take a PCD off, increasing the probability by 27.3%, followed by chief resident comments about the resident looking tired (16.6% increase), and having never heard their attendings comment about PCDs off as either positive or negative (13.9% increase). Factors that had the largest effect on decreasing the probability of taking a PCD were negative feedback about taking PCDs off (14.3% decrease), continuity of care concerns (10.8% decrease), and whether the resident was looking forward to an assignment (7.9% decrease).

CONCLUSIONS

The most important influencer of residents' decisions to take a PCD off was related to feedback from their attending physicians, suggesting that compliance with WHRs can be improved by focusing on the residency program's safety culture.

A gender biased hidden curriculum of clinical vignettes in undergraduate medical training

OBJECTIVES

Medical education relies extensively on clinical vignettes, yet little attention has been given to what hidden curriculum they might convey. Our research aimed to identify whether the clinical vignettes used in pre-graduate medical education transmit gender stereotypes or gender biases.

METHODS

We conducted a mixed quantitative and qualitative analysis of gender-related characteristics currently existing in clinical vignettes used for pre-graduate teaching and evaluation at the Geneva Faculty of Medicine.

RESULTS

2359 vignettes were identified, of which 955 met inclusion criteria. Patients' professions and family caregiver roles showed a strongly gendered distribution, as did the healthcare professions where male physicians and female nurses were the norm. Qualitative results identified widespread stereotyped gender roles and gender expression.

CONCLUSION

Our study reveals that the clinical vignettes used in education and evaluation materials in pre-graduate medical education in Geneva convey a gender-biased hidden curriculum, which could negatively impact patient care and undermine equal opportunity for men and women.

PRACTICE IMPLICATIONS

Active revision of the content and the form of clinical vignettes used in undergraduate medical education is needed using a gender lens. Based on rare gender neutral or gender transformative examples from our study, we propose guidelines for writing non-gender-biased vignettes.

Visual Misrepresentations: The Lack of Skin Tone and Sex Equity in General Surgical Textbooks

OBJECTIVE

Lack of racial and ethnic diversity in educational material contributes to health disparities. This study sought to determine if images of skin color and sex in general surgery textbooks were reflective of the U.S.

POPULATION

DESIGN

All human figures with discernable sex characteristics and/or skin tone were evaluated independently by 4 coders. Each image was categorized as male or female. Skin tone in each image was categorized using the Massey- Martin skin color scale. This data was compared to 2020 U.S. Census Data.

SETTING

U.S. Medical School.

PARTICIPANTS

Not applicable.

RESULTS

A total of 1179 images were evaluated for skin tone alone; 293 images for sex alone. 650 images depicted characteristics of both sex and skin tone. Interrater reliability was 0.78 for skin tone and 0.91 for sex. While the U.S. population is 59.3% white, 29.5% non-black persons of color and 13.6% black, in surgical textbooks, 90.7% of images were white, 6.5% were non-black persons of color, and 2.8% were black. Distribution of skin tone for all textbooks were significantly different. (p < 0.001) compared to the U.S.

POPULATION

The U.S. population is 49.5% male and 50.5% female. When images of sex specific genitalia and breasts are excluded, surgical textbook images are 62.9% male and 37.1% female. Only 1 textbook had a distribution of sex that was similar to the U.S.

POPULATION

CONCLUSIONS

Despite increasing diversity in the U.S. population there is a lack of skin tone and sex diversity in traditional surgical textbooks.

A Scoping Review of Educator Proficiency Interventions in Pharmacy Education Illustrated by an Interdisciplinary Model Integrating Pedagogical Theories into Practice

Pharmacy schools recognize the need for flexibility and comprehensive curricular transformation with a competency-based focus to effectively prepare for the evolving practitioner competencies and challenges of the pharmacy profession. The curricular implementation of evidence-based teaching and learning theories and practices demands educator proficiency through skills development with indispensable faculty leadership support. Our scoping review of online databases and pharmacy education-related journals aims to identify faculty development interventions or teaching proficiency programs that integrate educational and pedagogical theories. Original studies and reviews published between 2010 and 2022 were screened based on four inclusion criteria. Thirty-four manuscripts were eligible for full-text analysis, of which seven results referenced target faculty pedagogy knowledge development. Nine key messages, as Results Statements, synthesize and provide a framework for our results analysis. An ongoing Hungarian intervention model of comprehensive faculty development with strong interdisciplinary cooperation is discussed in our study to illustrate the applicability of the Results Statements through each stage of the process. Educator motivation and relatedness to students or awareness of the educator roles are intrinsic factors, which may not be easily detectable yet significantly impact teaching proficiency and student learning outcomes. The integration of evidence-based pedagogical knowledge and training in educator proficiency development contributes to the sustainability and cost-effectiveness of faculty interventions.

Industry Payments Received by Residents During Training

Importance

Those responsible for medical education-specialties, sponsoring institutions, and program directors (PD)-are independently associated with the professional identity formation of the trainees with respect to potential conflicts of interest.

Objective

To identify the relative degree to which factors in the training environment are associated with resident acceptance of payments from pharmaceutical and medical device companies.

Design, Setting, and Participants

Cross-sectional, retrospective study of residents enrolled in the 3 largest primary-care specialties (internal medicine [IM], family medicine [FM], obstetrics and gynecology [OBGYN]) and 3 largest surgical disciplines (general surgery [GS], orthopedic surgery, and urology) during academic year 2020 to 2021. All analyses were conducted January through August 2023.

Exposures

Specialty, sponsoring institutions' ownership (nonprofit, for-profit, federal government, local government, or state government), and the number of payments PDs accepted.

Main outcomes and measures

Modified Poisson regression assessed the relative risk of ownership, specialty, and PD behavior on residents' acceptance of industry payments as recorded in the Open Payments Program (OPP) database.

Results

In total, there were 124 715 residents in all training programs during 2020 to 2021, 12% of whom received payments totaling $6.4 million. There were 65 992 residents in training during 2020 to 2021 in the 6 specialties evaluated in this study, with 4438 in orthopedics, 1779 in urology, 9177 in GS, 5819 in OBGYN, 14 493 in FM, and 30 286 in IM. OPP records $3.9 million in payments to the 8750 residents (13.4%) who received at least 1 industry payment. The record of all payments to residents in OPP totals $6.4 million. Compared with residents in federal sponsoring institutions, those affiliated with for-profit institutions were 3.50 (95% CI, 2.32-5.28) times more likely to accept industry payments, while those affiliated with nonprofit organizations were 2.00 (95% CI, 1.36-2.93) times more likely to accept payments. Compared with IM, residents in each of the following specialties have an elevated risk of accepting payments: orthopedics, 3.21 (95% CI, 2.73-3.77) times; urology, 2.95 (95% CI, 2.44-3.56) times; GS, 1.21 (95% CI, 1.00-1.45) times; OBGYN, 1.30 (95% CI, 1.05-1.62) times. The difference in the risk of accepting a payment between FM and IM residents was not statistically significant. The number of payments PDs accepted slightly elevated the risk of residents to accept a payment by 1.01 (95% CI, 1.01-1.01).

Conclusions and relevance

In this cross-sectional, retrospective study, receipt of industry payments by residents was associated with specialty, institutional control, and PD behavior.

Lack of awareness of neurogastroenterology and motility within medical education: Time to fill the gap

Disorders of gut-brain interaction (DGBI), previously referred to as functional gastrointestinal disorders, affect 40.3% of adults in the general population and are diagnosed in 34.9% of new adult referrals to secondary care gastroenterology services. Despite their high prevalence, studies published in this issue of Neurogastroenterology and Motility by investigators based in Germany, the UK, and the USA demonstrate a mismatch between the clinical burden of DGBI and their representation in medical school and postgraduate curricula. This review outlines the salient findings of these studies and explores why and how negative perceptions toward DGBI exist, including factors related to misinformation and internalized stigma. The authors propose a selection of strategies to ameliorate physicians' attitudes toward and knowledge of neurogastroenterology and motility including linking trainees with dedicated clinician mentors with an interest in motility, exposing trainees to expert patients who can enhance empathy, extending Balint groups into gastroenterology training, and offering motility apprenticeships in specialist units. Urgent improvements to medical school and postgraduate curricula are required to ensure the longevity of this subspecialty field in gastroenterology, and to ensure the needs of a sizeable proportion of gastroenterology patients are appropriately met.

Preparing for the PICU: A Qualitative Study of Residents as They Prepare for Their First Pediatric Critical Care Rotation

Learning critical care medicine in the pediatric intensive care unit (PICU) can be stressful. Through semistructured interviews ( n  = 16), this study explored the emotions, perceptions, and motivations of pediatric medicine (PM) and emergency medicine (EM) residents, as they prepared for their first PICU rotation. Qualitative data were collected and analyzed using the grounded theory method. Three resultant themes emerged: (1) residents entered the PICU with a range of intense emotions and heightened expectations; (2) they experienced prior history of psychologically traumatic learning events (adverse learning experiences or ALEs); and (3) informed by ALEs, residents prepared for their rotation by focusing heavily on their most basic level of physiological needs and adopting a survival mindset prior to the start of the rotation. These three themes led to a substantive, or working, theory that ALE-associated events may affect how residents approach upcoming learning opportunities. Consequently, adapting a trauma-informed approach as a component of medical education may improve resident learning experiences in the PICU and beyond.

Revealing the impact of the hidden curriculum on faculty teaching: A qualitative study

INTRODUCTION

In health professions education, faculty may feel frustrated or challenged by aspects of their teaching. The concept of a hidden curriculum for students describes the expectations and assumptions enacted in educational programmes that tacitly impact students' learning experiences. A hidden curriculum has been suggested as a possible influence on faculty but has not been well explored. The aim of this study was to explain how a hidden curriculum might operate for faculty in health professions education.

METHODS

An interpretivist perspective was used to frame this qualitative study that examined one-on-one interview data generated with 16 faculty members from six different health care professions. Participants were asked to describe teaching experiences that they perceived as demanding. Using a hidden curriculum framework, descriptions of demanding teaching experiences were analysed inductively to identify relationships between a teacher's intended practice and what they could accomplish. These relationships were interpreted as the possible ways that a hidden curriculum was operating for faculty.

RESULTS

A hidden curriculum for faculty was found to operate in three ways by undervaluing the importance of having teaching expertise, undermining teaching goals through institutional conventions and perpetuating feelings of isolation.

DISCUSSION

A hidden curriculum for faculty can be represented as multiple overlapping domains and shape how faculty experience their teaching roles. The results provide examples that reveal how a hidden curriculum may operate for faculty. Faculty developers may find the insights provided by this study useful to make the hidden curriculum visible and help their faculty make sense of and navigate demanding teaching experiences.

Identifying self-presentation components among nursing students with unsafe clinical practice: a qualitative study

BACKGROUND

Maintaining patient safety is a practical standard that is a priority in nursing education. One of the main roles of clinical instructors is to evaluate students and identify if students exhibit unsafe clinical practice early to support their remediation. This study was conducted to identify self-presentation components among nursing students with unsafe clinical practice.

METHODS

This qualitative study was conducted with 18 faculty members, nursing students, and supervisors of medical centers. Data collection was done through purposive sampling and semi-structured interviews. Data analysis was done using conventional qualitative content analysis using MAXQDA10 software.

RESULTS

One main category labelled self-presentation emerged from the data along with three subcategories of defensive/protective behaviors, assertive behaviors, and aggressive behaviors.

CONCLUSION

In various clinical situations, students use defensive, assertive, and aggressive tactics to maintain their professional identity and present a positive image of themselves when they make a mistake or predict that they will be evaluated on their performance. Therefore, it seems that the first vital step to preventing unsafe behaviors and reporting medical errors is to create appropriate structures for identification, learning, guidance, and evaluation based on progress and fostering a growth mindset among students and clinical educators.