The Hidden Curricula of Medical Education: A Scoping Review

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.

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.

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.

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.

"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.

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.

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.

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.

Perceptions of medical students and their facilitators on clinical communication skills teaching, learning, and assessment

Introduction

Despite various efforts to develop communication skills (CS) in the classroom, the transfer of these skills into clinical practice is not guaranteed. This study aimed to identify barriers and facilitators of transferring CS from the classroom to clinical environments.

Methods

A qualitative study was conducted at one Australian medical school to explore the experiences and perceptions of facilitators and students in relation to teaching and learning clinical CS. Thematic analysis was used to analyze data.

Results

Twelve facilitators and sixteen medical students participated in semi-structured interviews and focus-group discussions, respectively. Primary themes included the value of teaching and learning, alignment between approaches to teaching and actual clinical practices and students' perceptions of practice, and challenges in different learning environments.

Discussion

This study reinforces the value of teaching and learning CS by facilitators and students. Classroom learning provides students with a structure to use in communicating with real patients, which can be modified to suit various situations. Students have limited opportunities, however, to be observed and receive feedback on their real-patient encounters. Classroom session that discussed CS experiences during clinical rotation is recommended to strengthen learning both the content and process of CS as well as transitioning to the clinical environment.

Didactic dissonance-embracing the tension between classroom and clinical education

The United States is undergoing a transformation in the way pain is viewed and treated. This transformation affects pain education, as some degree of disconnect will be expected between what is taught in classroom settings and what learners observe in clinical settings. We term this disconnect "didactic dissonance" and propose a novel process to harness it as a learning tool to further pain education. Based on principles of transformative learning theory, we describe a structured, three-step process beginning with (1) priming learners to recognize didactic dissonance and identify specific examples from their education, followed by (2) encouraging learners to search the primary literature to resolve observed dissonance and reflect on the system factors that created and perpetuated the disconnect, and then (3) providing an opportunity for learner reflection and planning for how they will address similar situations in future practice and teaching environments. Fostering an environment conducive to learning-through modeling the intellectual virtues of curiosity, humility, and creativity-is a critical task for educators when implementing this process. Recognizing challenges faced by educators in both classroom and clinical settings, it may be a more feasible first step to integrate the concept of didactic dissonance into existing curricular elements. For programs able to implement the full three-step process, a discussion guide along with an example of a facilitated discussion have been provided. While proposed in the context of pain education, this transformational approach can be utilized across all topics in medical education to foster autonomous lifelong learning.

Flipping the hidden curriculum to transform pain education and culture

Though long-sought, transformation of pain management practice and culture has yet to be realized. We propose both a likely cause-entrenchment in a biomedical model of care that is observed and then replicated by trainees-and a solution: deliberately leveraging the hidden curriculum to instead implement a sociopsychobiological (SPB) model of care. We make use of Implicit Bias Recognition and Management, a tool that helps teams to first recognize and "surface" whatever is implicit and to subsequently intervene to change whatever is found to be lacking. We describe how a practice might use iterations of recognition and intervention to move from a biomedical to a SPB model by providing examples from the Chronic Pain Wellness Center in the Phoenix Veterans Affairs Health Care System. As pain management practitioners and educators collectively leverage the hidden curriculum to provide care in the SPB model, we will not only positively transform our individual practices but also pain management as a whole.

Towards an autonomy-supportive model of wellness in Canadian medical education

Purpose

Learner distress is a huge problem in medicine today, and medical institutions have been called upon to help solve this issue. Unfortunately, the majority have responded not by addressing the system and culture that have long plagued the profession, but by creating individual-focused "wellness" interventions (IFWs). As a result, medical learners are routinely being forced to undergo training on resilience, mindfulness, and burnout.

Approach

Grounded in well-supported theory and empirical evidence, my central argument in this commentary is that IFWs are inappropriate, insulting, and psychologically harmful to learners, and that they need to stop.

Contribution

Extending prior work in this area, I first present three fundamental problems with IFWs. I then recommend a paradigm shift in how we are approaching "wellness" in medical education.

Conclusion

Finally, I provide an evidence-based roadmap, in self-determination theory, for how system-level improvements could be made in a timely, sustainable, and socially responsible way, that would benefit everyone in medicine-from leaders, to educators, to learners, to patients.

Patientology revisited: Toward tailored care pathways

BACKGROUND

Concepts such as patient-centred care, patient empowerment and patient participation have challenged our understanding of what it means to be a patient and what role patients play in care pathways. Consequently, patientology as the medical sociological and anthropological study of patients is currently being reconceptualized through perspectives of health as individualized and privatized capital.

AIMS

This article explores the potential of such a patientological perspective to enhance our understanding of and tailor care pathways. Particularly, we aim to investigate how such a perspective can contribute to tailoring care pathways to the capacities of individual patients and their relatives.

MATERIALS & METHODS

We elaborate on an emerging health capital-theoretic model for patientology and study its potential for optimizing care pathways through two distinct cases of care contexts: communicative challenges in the context of integrative primary care for vulnerable chronically ill multi-morbid patients and the potential of parent involvement in the acute hospitalization of children suspected to be affected by multisystem inflammatory syndrome in children.

RESULTS

Our results shed light on the importance of cultural and social capital of patients and their relatives in the design of effective tailored care pathways. We find that a lack of cultural and social capital presents a significant barrier to effective communication between patients and the healthcare professionals involved in their care pathways. We also find that understanding the cultural and social capital of relatives provides an entry point to their effective involvement in the care pathways of their children.

DISCUSSION & CONCLUSION

The implications of these findings extend beyond the concrete care contexts studied. This article contributes to our understanding of care pathways through a perspective of health inequalities being based on differences in health capital and demonstrates how the health capital-theoretic patientology model facilitates the systematic development of guidelines for healthcare professionals to assess patients' resources and tailor their care pathways accordingly.

A Scoping Review of the Hidden Curriculum in Pharmacy Education

Objective. The hidden curriculum has been defined as teaching and learning that occur outside the formal curriculum and includes the knowledge, skills, attitudes, behaviors, values, and beliefs that students consciously or subconsciously acquire and accept. It has been identified as an inherent part of learning in health professions education and may affect students' formation of professional identity. This scoping review investigated the definition and evidence of the hidden curriculum for pharmacy education.Findings. A comprehensive literature search was conducted for primary articles investigating the hidden curriculum in pharmacy education through August 2021. A total of five papers were included in the review: four papers from the United Kingdom and one from Sweden. The focus of each paper and the elements of the hidden curriculum, along with the study quality as assessed by the quality assessment tool, varied. Three papers focused on professionalism or professional socialization, and the other two focused on patient safety. All five studies used qualitative methods including focus groups and semistructured interviews of the students and faculty. Studies also identified approaches to addressing the hidden curriculum, such as integrating formal and informal learning activities, integrating work experiences, providing sustained exposure to pharmacy practice, and development of professionalism.Summary. The definition of the hidden curriculum varied across the five studies of varying quality. The evidence of the hidden curriculum was measured qualitatively in experiential and academic settings. Recognition of the impact of the hidden curriculum and strategies for addressing its negative effects are critical to the success of not only the students but also the pharmacy profession at large.

Clinical associate students' perceptions of factors that influence their developing professional identity: a qualitative study

BACKGROUND

New cadres of clinicians, known as clinical associates, physician assistants, or clinical officers have evolved globally within many health systems to broaden access to care by increasing human resources. The training of clinical associates started in 2009 in South Africa, entailing the attainment of knowledge, clinical skills, and attitude competencies. Less formal educational attention has been focused on the process of developing personal and professional identities.

METHOD

This study utilized a qualitative interpretivist approach to explore professional identity development. A convenient sample of 42 clinical associate students at the University of Witwatersrand in Johannesburg were interviewed using focus groups to explore their perceptions of factors that influenced their professional identity formation. A semi-structured interview guide was used in six focus group discussions, involving 22 first-year and 20 third-year students. The transcriptions from the focus group audio recordings were thematically analyzed.

RESULTS

The multi-dimensional and complex factors that were identified were organized into three overarching themes, identified as individual factors which derive from personal needs and aspirations, training-related factors consisting of influences from the academic platforms, and lastly, student perceptions of the collective identity of the clinical associate profession influenced their developing professional identity.

CONCLUSION

The newness of the identity of the profession in South Africa has contributed to dissonance in student identities. The study recognizes an opportunity for strengthening the identity of the clinical associate profession in South Africa through improving educational platforms to limit barriers to identity development and effectively enhancing the role and integration of the profession in the healthcare system. This can be achieved by increasing stakeholder advocacy, communities of practice, inter-professional education, and the visibility of role models.

Development and validation of a questionnaire about hidden curriculum in medical institutes: A pilot study

The goal of the current study was to develop and validate a questionnaire that would reveal characteristics of medical hidden curricula. It is an extension of the qualitative research that was done by researchers on hidden curriculum, and a second part of the qualitative was the creation of a questionnaire by a panel of experts. Using both exploratory factor analysis (EFA) and the quantitative portion, the questionnaire was verified. The sample size was 301, and the participants, who were from medical institutes, were both genders and between the ages of 18 and 25. First, a thematic analysis of the qualitative portion was used to create a 90-item questionnaire. The validity of the questionnaire's content was certified by the expert panel. A 39-item questionnaire was subsequently created after the items that overlapped and the items that did not represent the particular theme were eliminated. After that, we validated the survey. A total of 39 high-loading components made up the six variables of EFA, which explained 62% of the variance. The 33-item questionnaire, from which six items were deleted, was found to have satisfactory psychometric qualities. As a result, the accountability of faculty and students in curricula and extracurricular activities combined with equal opportunity is one factor, communication and relationships with stakeholders combined with evidence-based reforms and implementations are the second factors, and student-centeredness and empowerment as the third main factor of the hidden curriculum are all considered to be important factors. All these three main constructs were collectively used to measure hidden curricula in medical institutes.

One test to rule them all: A qualitative study of formal, informal, and hidden curricula as drivers of USMLE "exam mania"

High-stakes examinations are an integral part of medical education. To practice in the United States (U.S.), students must pass the U.S. Medical Licensing Examinations (USMLE). With the transition of USMLE Step 1 to pass/fail scoring on January 26, 2022, a worldwide debate regarding how residency program directors will view the Step 2 Clinical Knowledge (CK) exam emerged. Here, the authors explore the role of formal, informal, and hidden curricula related to USMLE, with broader implications for high-stakes examinations. Six focus groups of fourth-year students who recently took Step 2 CK and a supplemental curricular content analysis were conducted to explore students' decision-making and emotions regarding the exam, including how the formal, informal, and hidden curricula influence their perspectives. Participants highlighted how informal and hidden curricula drive the belief that high-stakes examinations are the single most important factor in medical school. Prior experience with Step 1 drives behaviors and attitudes when preparing for Step 2 CK. Pressures from these examinations have unintended consequences on burnout, professional identity, specialty choice, and interpersonal interactions. Both interpersonal interactions within medical education as well as subconscious, unintended messaging can influence medical student approaches to and perspectives about high-stakes examinations. Within the context of U.S. medical training, with the transition to a new era of a pass/fail Step 1 examination, careful consideration to prevent shifting the current "Step 1 mania" to a "Step 2 CK mania" is warranted. More broadly, medical educators must examine the unintended yet potentially damaging pressures institutions generate in their medical trainees in relation to high-stakes examinations.

Revealing the Hidden Clerkship Curriculum: A Qualitative Analysis

BACKGROUND AND OBJECTIVES

Family medicine (FM) clerkships have learning objectives to define what students should learn by the end of their clerkship, but how do we know what larger lessons students are taking away? This study aimed to explore the FM clerkship explicit and hidden curriculum.

METHODS

Students were asked to list their top five take-home points at the end of their FM clerkship at two institutions. A total of 668 written reflections were qualitatively analyzed.

RESULTS

Thirteen code categories emerged: scope of practice, health care systems, role of FM in the system, traits of a family doctor, values of FM, cultural competency and social justice, challenges of FM care, evidence-based medicine, clinical skills for a student, personal impact, life skills and tips, patient centeredness, and clinical pearls. Prominent subcategories included prevention, team-based care, doctor-patient relationship, and continuity of care.

CONCLUSIONS

When compared to the FM clerkship learning objectives at both institutions, four code categories emerged that were not part of the explicit objectives: traits of a family doctor, challenges in FM care, personal impact, and life skills and tips. Conversely, some nuances of the learning objective of FM in the health care system regarding decreasing cost and improving health outcomes and equity were not represented in the coded categories of student responses. These findings could potentially help FM clerkships nationally define ways to improve messaging around challenges in FM care and help the 25 x 2030 initiative to produce more family physicians in the United States.

In the eye of the beholder - how course delivery affects anatomy education

BACKGROUND

The COVID-19 pandemic caused major shifts in students' learning strategies as well as teaching environments that profoundly affected the delivery of anatomy courses in medical schools. The Department of Anatomy at the University of Zagreb School of Medicine had a unique experience where the anatomy course in 2019/2020 was first taught in-person before transferring to an online course delivery, while the inverse happened in 2020/2021. The core curriculum, course material and examination criteria were the same in both academic years. The aim of the study was to determine whether course delivery affected students' perceptions of the course and whether it impacted students' engagement and success.

METHODS

The students' perceptions of the course were assessed via an anonymous course survey (student evaluation of teaching, SET). The questions in the SET assessed the usefulness of teaching modalities rather than students' satisfaction. Most questions were in the form of statements to which students responded with their level of agreement on a five-point Likert scale. Differences between responses in 2019/2020 and 2020/2021 were analyzed using the Mann-Whitney test. Effect size was estimated using Cliff's delta and association between responses was assessed using Spearman's r coefficient.

RESULTS

Students' perceptions were significantly affected by changes in course delivery. Students' success and engagement were higher in 2019/2020 when in-person teaching preceded online teaching. Furthermore, students' views on course organization and the usefulness of continuous assessment were more positive in 2019/2020. Finally, students' perceptions of the usefulness of online materials and activities were more positive in 2019/2020. All comparisons between the two academic years were statistically significant (P ≤ 0.0001 for all comparisons, Mann-Whitney test).

CONCLUSIONS

Students' perceptions of the anatomy course were dependent on the teaching environment they were exposed to at the beginning of the course. A transfer from in-person to online course delivery was more successful than vice-versa. This has important implications for structuring hybrid courses in medical education in the future.

A critical interpretive synthesis of power and mistreatment of women in maternity care

Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one's rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination against indigenous women), organizational (e.g. pressure to achieve performance goals), and law/policy (e.g. lack of accountability for rights violations). Most papers addressed more than one level of the social-ecological model, though a significant minority were focused just on interpersonal factors. During Phase 1, we identified priority themes relating to under-explored power-related drivers of MoW for exploration in Phase 2, including lack of conscientization and normalization of MoW; perceptions of fitness for motherhood; geopolitical and ethnopolitical projects related to fertility; and pressure to achieve quantifiable performance goals. We ultimately included 104 papers in Phase 2. The wide-ranging findings from Phase 3 (synthesis and analysis) coalesce in several key meta-themes, each with their own evidence-base for action. Consistent with the notion that research on power can point us to "drivers of the drivers," the paper includes some intervention-relevant insights for further exploration, including as relating to broader social norms, health systems design, and the utility of multi-level strategies.

Teaching perspectives on the communication of difficult news of genetic conditions to medical students

Informing parents that their child has a diagnosis of Down syndrome (DS) is a common example of the delivery of unexpected or difficult news. Expectations and life planning will change, and if detected prenatally, discussions might include the option of pregnancy termination. Medical school curricula currently include training in breaking unexpected news; however, it is difficult to teach and assess. We use the perspectives of clinicians, educators, and a medical student who is the parent of a child with DS to frame a discussion on teaching, practicing, and assessing communication of difficult news in human genetics during medical school.

Interprofessional Identity in Health and Social Care: Analysis and Synthesis of the Assumptions and Conceptions in the Literature

Interprofessional identity (IPI) development is considered essential in reducing incongruency and improving interprofessional collaboration. However, noticeable differences in conceptualizations are being put forward in the literature, hindering interpretation of research findings and translation into practice. Therefore, a Concept Analysis and Critical Interpretative Synthesis of empirical research articles were conducted to explore the assumptions and conceptions of IPI. Independent literature screening by two researchers led to the inclusion and extraction of 39 out of 1334 articles. Through critical analysis, higher order themes were constructed and translated to a synthesizing argument and a conceptual framework depicting what constitutes IPI (attributes), the boundary conditions (antecedents) and the outcomes (consequences) of its development. The attributes refer to both IPI's structural properties and the core beliefs indicative of an interprofessional orientation. The antecedents inform us on the importance of IPI-fitting constructivist learning environments and intergroup leadership in enabling its development. This development may lead to several consequences with regard to professional wellbeing, team effectiveness and the quintuple aim. Given the educational orientation of this study, ways for facilitating and assessing the development of IPI among learners across the professional continuum have been proposed, although empirical research is needed to further validate links and mediating and moderating variables.

Cultural historical activity and the complexity of health professions education

Commenting on Hu et al., Grainger and Gladman comment on how the purpose of student‐led community learning can change focus from the development of technical and professional skills to the aspirations and goals of the community in which students work.

Curriculum mapping of health promotion competencies in dental and oral health training programmes in Australia

ISSUE ADDRESSED

Dental diseases are chronic conditions that place a significant burden on the population's health; however, they are mostly preventable using a range of health promotion strategies Health promotion is a core competency for all dental and oral health graduates, but little is known about what health promotion content is taught in undergraduate degrees. The aim of this study was to explore the dental and oral health content in Australian undergraduate dental and oral health degrees and map against the last two versions of the Australian Dental Council (ADC) health promotion competencies.

METHODS

All ADC-accredited dental and oral health courses delivered at Australian universities in 2019 were eligible to be included. Key words were used to locate subjects within the courses that contained health promotion content. This was analysed and ranked against the last two versions (2011 and 2016) of the ADC health promotion competencies. The competencies were then ranked using Blooms updated "six levels of thinking."

RESULTS

Seven oral health and eight dental courses were mapped. The number of health promotion subjects in courses varied substantially; the percentage of subjects that contained health promotion in oral health courses ranged from 30% to 75% and 16% to 60% for dental courses. All oral health courses were explicitly meeting the current ADC health promotion competencies, however, only half of the dental courses met the competency standards.

CONCLUSION

Curriculum mapping provided a snapshot of the health promotion content within dental and oral health degrees in Australia. Evaluations of the extent to which these courses meet the ADC competencies provide useful information for students, clinicians and policy makers. SO WHAT?: This study provides evidence that health promotion training is occurring at varying levels. However, in dentistry, not all the ADC health promotion competencies are being met. A change is needed in the ADC health promotion competencies and ethos of academics involved in the development of curriculum to include and give appropriate attention to health promotion theory, especially advocacy. This will enable future dental professionals to advocate for a range of oral health promotion activities such as water fluoridation, universal dental care and sugar-sweetened beverage taxes.

Identity Development in Disorientating Times: the Experiences of Medical Students During COVID-19

INTRODUCTION

Professional identity development is a central aim of medical education, which has been disrupted during COVID-19. Yet, no research has qualitatively explored COVID-19's impact across institutions or countries on medical students' identities. Kegan proposes a cognitive model of identity development, where 'disorientating dilemmas' prompt student development. Given the potential of COVID-related disruption to generate disorientating dilemmas, the authors investigated the ways in which COVID-19 influenced students' identity development.

METHODS

The authors conducted an international qualitative study with second year medical students from Imperial College London, and third year students from Melbourne Medical School. Six focus groups occurred 2020-2021, with three to six students per group. Authors analysed data using reflexive thematic analysis, applying Kegan's model as a sensitising theoretical lens.

RESULTS

COVID-19 has resulted in a loss of clinical exposure, loss of professional relationships, and a shift in public perception of physicians. Loss of exposure to clinical practice removed the external validation from patients and seniors many students depended on for identity development. Students' experiences encouraged them to assume the responsibilities of the profession and the communities they served, in the face of conflicting demands and risk. Acknowledging and actioning this responsibility facilitated identity development as a socially responsible advocate.

CONCLUSIONS

Educators should consider adapting medical education to support students through Kegan's stages of development. Measures to foster relationships between students, patients, and staff are likely necessary. Formal curricula provisions, such as spaces for reflection and opportunities for social responsibility, may aid students in resolving the conflict many have recently experienced.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01592-z.

Association between patient care ownership and personal or environmental factors among medical trainees: a multicenter cross-sectional study

BACKGROUND

Patient care ownership (PCO) is crucial to enhancing accountability, clinical skills, and medical care quality among medical trainees. Despite its relevance, there is limited information on the association of personal or environmental factors with PCO, and thus, authors aimed to explore this association.

METHODS

In 2021, the authors conducted a multicentered cross-sectional study in 25 hospitals across Japan. PCO was assessed by using the Japanese version of the PCO Scale (J-PCOS). To examine the association between personal (level of training, gender, and department) or environmental factors (hospital size, hospital type, medical care system, number of team members, number of patients receiving care, mean working hours per week, number of off-hour calls per month, and perceived level of the workplace as a learning environment) and PCO after adjusting for clustering within hospitals, the authors employed a linear mixed-effects model.

RESULTS

The analysis included 401 trainees. After adjusting for clustering within hospitals, it was confirmed that the senior residents had significantly better J-PCOS total scores (adjusted mean difference: 8.64, 95% confidence interval [CI]: 6.18-11.09) than the junior residents and the perceived level of the workplace as a learning environment had a positive association with J-PCOS total scores (adjusted mean difference per point on a global rating of 0-10 points: 1.39, 95% CI: 0.88-1.90). Trainees who received calls after duty hours had significantly higher J-PCOS total scores than those who did not (adjusted mean difference: 2.51, 95% CI: 0.17-4.85). There was no clear trend in the association between working hours and PCO.

CONCLUSIONS

Seniority and the perceived level of the workplace as a learning environment are associated with PCO. An approach that establishes a supportive learning environment and offers trainees a reasonable amount of autonomy may be beneficial in fostering PCO among trainees. The study findings will serve as a useful reference for designing an effective postgraduate clinical training program for PCO development.

Transforming an educational ecosystem for substance use disorders: A multi-modal model for continuous curricular improvement and institutional change

Health professions curricula are created to prepare learners to effectively address health issues affecting individ uals and their communities. Ideally, curricula emphasize the predominant biopsychosocial influences impacting the health of diverse populations. However, despite decades of investment and advances in educational research and design, we have failed to create a health professional workforce capable of equitably meeting the health care needs of the public. Particular communities, geographic regions, and patients with stigmatized diagnoses continue to be underserved, and the potential contributions of multidisciplinary health professionals and advanced practice providers continue to be unrealized within a predominantly physician-centric health care model. Genuine educational transformation requires multidimensional, iterative strategies used to meaningfully evolve traditional classroom curricula, break from the implicit and "hidden" curricula, and enrich the educational ecosystem in which all operate. This manuscript elaborates the construct and process of "educational ecosystem transformation" as a tool for the evolution of the educational ecosystem and its situated curriculum that will eventually drive the enrichment of the healthcare workforce. Drawing from traditional models of curriculum development, recent work on transforming the hidden curriculum, the clinical learning environment, and change management strategies, this new approach uses a health equity and structural competence lens to interrogate and deconstruct a learning system in order to identify opportunities to change, strengthen, and deepen a learner's experience around a specific topic. This process requires an in-depth, multidimensional assessment followed by the identification of key change targets and a stepwise, iterative plan for improvement and transformation. The topic area of substance use disorders (SUD) is used to illustrate how this complex process might be employed to improve the quality of care, realize and amplify the contributions of the entire healthcare team, stimulate interest in addiction medicine as a career, and reduce the stigma and disparities patients with SUDs often experience.

Calling situated: a survey among medical students supplemented by a qualitative study and a comparison with a surveyed sample of physicians

BACKGROUND

Calling within the medical context receives growing academic attention and empirical research has started to demonstrate its beneficial effects. The purpose of this study is to investigate what motivates students to enter medical school and what role calling may play (i), to evaluate if calling influences the way in which they experience their studies (ii), and to compare medical students' experience of calling with those of physicians.

METHODS

A questionnaire survey was distributed among medical students (N = 1048; response rate above 60%) of the University of Lausanne in Switzerland. It was supplemented by a group discussion between bachelor medical students (N = 8) and senior physicians (N = 4), focusing on different facets of calling. An existing data set of a survey among physicians, addressing calling with the same questionnaire, was used to compare students' and physicians' attitudes towards calling. Survey data were analyzed with the habitual statistical procedures for categorical and continuous variables. The group discussion was analyzed with thematic analysis.

RESULTS

The survey showed that experiencing calling is a motivational factor for study choice and influences positively choice consistency. Students experiencing calling differed from those who did not: they attributed different definitions to calling, indicated more often prosocial motivational factors for entering medical school and perceived the learning context as less burdensome. The analysis of the group discussion revealed that the concept of calling has a fluid definition. It was conceived as having the characteristics of a double-edged sword and as originating from within or outside or from a dialectic interplay between the inner and outer world. Finally, calling is experienced less often by physicians than by medical students, with a decreasing prevalence as the immersion in the clinical years of the study of medicine progresses.

CONCLUSIONS

Calling plays an important role in study choice and consistency of medical students. Given its relevance for medical students and its ramifications with the learning context, calling should become a topic of the reflexive parts of the medical curriculum. We critically discuss the role played by calling for medical students and provide some perspectives on how calling could be integrated in the reflection and teaching on physicianhood.

Perspectives of Nursing Students on Promoting Reflection in the Clinical Setting: A Qualitative Study

Background: Reflection increases meta-cognitive capacities, promotes student-instructor relationships, overcomes the theory-practice gap, and enriches learning. This study aims at exploring nursing students’ perspectives on the facilitators of reflective practices in the clinical setting. Methods: Semi-structured interviews were conducted among 21 Saudi nursing students at one major university in Saudi Arabia. Results: Two major themes were prevalent upon thematic analysis, namely, “Personal Drivers of Reflection” which consisted of “Motivation to Learn”, “Desire to develop”, “Ethical Regard”, and “Responsibility towards patients” and “External Drivers of Reflection” which consisted of “Patient characteristics”, “Case complexity”, and “Competent Instructors”. Conclusion: As per the results of the study, nursing students perceived that they underwent reflection as a response to personal motivational and external educational aspects. According to the findings, instructors should assist students through clinical reflection, with a special focus on their interactions and motivation.

Third year medical student knowledge gaps after a virtual surgical rotation

INTRODUCTION

This study describes perceived knowledge gaps of third-year medical students after participating in a virtual surgical didactic rotation (EMLR) and shortened in-person surgery rotation during the COVID-19 Pandemic.

METHODS

Open-ended and Likert questions were administered at the end of the virtual rotation and inperson-surgical rotation to medical students. Three blinded coders identified themes by semantic analysis.

RESULTS

82 students (51% of all MS3s) participated in the EMLR. Semantic analysis revealed gaps in perioperative management (Post-EMLR:18.4%, Post-Inpatient:26.5%), anatomy (Post-EMLR:8.2%, PostInpatient:26.5%). and surgical skills (Post-EMLR: 43.0%, Post-Inpatient: 44.1%). Students also described gaps related to OR etiquette (Post-EMLR: 12.2%, Post-Inpatient: 8.8%) and team dynamics/the hidden curriculum (Post- Inpatient:26.6%). There was a significant improvement in perceived confidence to perform inpatient tasks after completing the inpatient clinical experience (p ≤ 0.01).

CONCLUSION

Virtual interactive didactics for cognitive skills development cannot replace a full clinical surgical experience for third-year medical students. Future curricula should address perceived gaps.

Improving Financial Literacy Using the Medical Mini-MBA at a Canadian Medical School

Introduction

Financial literacy correlates with less debt and better retirement planning. Medical students, residents, and physicians often have poor financial literacy and large amounts of debt. We measured baseline financial literacy and whether it improved with the administration of a financial literacy course.

Methods

We created the Medical Mini-MBA,a six-week financial literacy course that targeted gaps in financial literacy among medical students and residents. Weekly topics included personal finance, investing, real estate and mortgage, physician billing and payment models, income and tax, and choosing a medical specialty. A 46-question financial literacy assessment was delivered to participants before and after the course.

Results

Of the 276 who participated in the course, 179 (64.86%) participated in the study. Participants who completed the course improved their financial literacy score by 10.10/46.00±5.12 (n=93, p<0.001). Self-assessment of financial literacy was positively correlated with financial literacy exam scores (r=0.366, p<0.001). Demographics such as gender, geography, education level, and first-degree relatives who are/were physicians had no effect on financial literacy scores.

Conclusions

The Medical Mini-MBA improved financial literacy at a Canadian medical school. Implementation of the coursemay equip medical students and residents for financial decisions. It avoids financial conflicts of interest and can supplement the medical curriculum.

Planning a Collection of Virtual Patients to Train Clinical Reasoning: A Blueprint Representative of the European Population

Background: Virtual patients (VPs) are a suitable method for students to train their clinical reasoning abilities. We describe a process of developing a blueprint for a diverse and realistic VP collection (prior to VP creation) that facilitates deliberate practice of clinical reasoning and meets educational requirements of medical schools. Methods: An international and interdisciplinary partnership of five European countries developed a blueprint for a collection of 200 VPs in four steps: (1) Defining the criteria (e.g., key symptoms, age, sex) and categorizing them into disease-, patient-, encounter- and learner-related, (2) Identifying data sources for assessing the representativeness of the collection, (3) Populating the blueprint, and (4) Refining and reaching consensus. Results: The blueprint is publicly available and covers 29 key symptoms and 176 final diagnoses including the most prevalent medical conditions in Europe. Moreover, our analyses showed that the blueprint appears to be representative of the European population. Conclusions: The development of the blueprint required a stepwise approach, which can be replicated for the creation of other VP or case collections. We consider the blueprint an appropriate starting point for the actual creation of the VPs, but constant updating and refining is needed.

Effective competency-based medical education requires learning environments that promote a mastery goal orientation: A narrative review

PURPOSE

Competency-based medical education (CBME) emphasizes the need for learners to be central to their own learning and to take an active role in learning. This approach has a dual aim: to encourage learners to actively engage in their own learning, and to push learners to develop learning strategies that will prepare them for lifelong learning. This review paper proposes a theoretical bridge between CBME and lifelong learning and puts forth the argument that in order for CBME programs to produce the physicians truly needed in our society now and in the future, learning environments must be intentionally designed to foster mastery goal orientations and to support the development of adaptive self-regulated learning skills and behaviours.

MATERIALS AND METHODS

This narrative literature review incorporated results of searches conducted by a subject librarian in PsycInfo and MedLine. Articles were also identified through reference lists of identified papers to capture older key citations. Analysis of the literature used a constructivist epistemological approach to develop an integrative description of the interaction of achievement goal orientation, self-regulated learning, learning environment, and lifelong learning.

RESULTS

Findings from achievement goal theory research support the assumption that adoption of a mastery goal orientation facilitates the use of adaptive learning behaviours, such as those described in self-regulated learning theory. Adaptive self-regulated learning strategies, in turn, facilitate effective lifelong learning. The authors offer evidence for how learning environments influence goal orientations and self-regulated learning, and propose that CBME programs intentionally plan for such learning environments. Finally, the authors offer specific suggestions and examples for how learning environments can be designed or adjusted to support adoption of a mastery goal orientation and use of self-regulated learning behaviours and strategies to help support development of adaptive lifelong learners.