Taking Students as They Should Be: Restoring Trust in Undergraduate Medical Education

The Case for Brutalist Honesty in Medical Education

Introduction

The assumption of a prioi trust between students and institutions of medical education is anachronistic and promotes both unnecessary student anxiety and the adoption of hidden curriculums to offset perceived risk due to a lack of transparency. Compared to the past, students now have access to a wealth of outside data to evaluate their curricular progress and career prospects against, and yet institutions are lagging behind in openly disclosing information related to metrics of student success (course passing rates, number of repeat students per class, Step 1 pass rate, etc.) that would engender trust and afford students greater agency in their academic decisions.

Approach

In developing a new academic counseling office, the author deployed a method of using brutalist honesty as a means of student support, both in terms of answering all curriculum questions truthfully no matter the topic and with individualized data analytics to provide objective evidence as to student performance progress. The overarching goal was to foster student trust and have a positive relationship, both of which are necessary to give meaningful recommendations.

Outcomes

As a result, the 2023 graduating medical school class, the first class to go through a full 4 years of this approach, rated the academic counseling office with a 96.2% satisfaction rate. This is above the national average of 88.1%, and the class performed 9 points higher than the institution's three-year historical average on Step 1.

Next Steps

Our goal is to maintain this approach to see if student satisfaction continues to remain high, or if given time, brutalist honesty becomes an assumed trait of the program. Additionally, we aim to push for high-quality research into student perceptions of trust and the impact that has on their academic outcomes.

How medical students' trauma histories affect their clinical clerkship experiences

BACKGROUND

As the gender demographics of medical students have evolved over the past decades, it is important to understand potential stressors and challenges that may affect clinical learning experiences. This study investigated the prevalence of prior sexual assault (SA) and interpersonal violence (IPV) in medical students and how these affect their clinical clerkship experiences.

METHODS

A survey was distributed to third- and fourth-year medical students at a single institution in August 2022 querying respondents on demographics and prior experiences with SA/IPV at any point in their lives. Respondents who indicated they had previously experienced SA/IPV were directed to questions about how these experiences affected clerkships.

FINDINGS

Of 419 students, 125 responded to the survey (30.8% response rate). Forty (31.1%) reported a history of SA/IPV-32 (80.0%) women, five (12.5%) men, and three (7.5%) who did not report gender or identified as non-binary. Of the 40 respondents with a history of SA/IPV, 20 (50.0%) reported that their prior history affected their overall clinical experience, and nine (22.5%) felt that it affected their performance. Only seven (17.5%) reported using any resources, such as counselling, during their clerkships. Narrative responses discussed significant effects on performing physical exams, taking a history, interacting with team members, and engaging during clerkships.

DISCUSSION

This work demonstrates the high number of students affected by SA/IPV and how these prior experiences affected core components of their clerkship experiences.

CONCLUSIONS

Institutions must be proactive to create better supports for learners with histories of trauma, including SA/IPV.

The Problematic Persistence of Tiered Grading in Medical School

Issue: The evaluation of medical students is a critical, complex, and controversial process. It is tightly woven into the medical school curriculum, beginning at the inception of the medical student's professional journey. In this respect, medical student evaluation is among the first in a series of ongoing, lifelong assessments that influence the interpersonal, ethical, and socioeconomic dimensions necessary for an effective physician workforce. Yet, tiered grading has a questionable historic pedagogic basis in American medical education, and evidence suggests that tiered grading itself is a source of student burnout, anxiety, depression, increased competitiveness, reduced group cohesion, and racial biases. Evidence: In its most basic form, medical student evaluation is an assessment of the initial cognitive and technical competencies ultimately needed for the safe and effective practice of contemporary medicine. At many American medical schools, such evaluation relies largely on norm-based comparisons, such as tiered grading. Yet, tiered grading can cause student distress, is considered unfair by most students, is associated with biases against under-represented minorities, and demonstrates inconsistent correlation with residency performance. While arguments that tiered grading motivates student performance have enjoyed historic precedence in academia, such arguments are not supported by robust data or theories of motivation. Implications: Given the evolving recognition of the deleterious effects on medical student mental health, cohesiveness, and diversity, the use of tiered grading in medical schools to measure or stimulate academic performance, or by residency program directors to distinguish residency applicants, remains questionable. Examination of tiered grading in its historical, psychometric, psychosocial, and moral dimensions and the various arguments used to maintain it reveals a need for investigation of, if not transition to, alternative and non-tiered assessments of our medical students.

An Innovative Undergraduate Medical Curriculum Using Entrustable Professional Activities

The need to educate medical professionals in changing medical organizations has led to a revision of the Radboudumc's undergraduate medical curriculum. Entrustable professional activities (EPAs) were used as a learning tool to support participation and encourage feedback-seeking behavior, in order to offer students the best opportunities for growth. This paper describes the development of the Radboudumc's EPA-based Master's curriculum and how EPAs can facilitate continuity in learning in the clerkships. Four guiding principles were used to create a curriculum that offers possibilities for the students' development: (1) working with EPAs, (2) establishing entrustment, (3) providing continuity in learning, and (4) organizing smooth transitions. The new curriculum was designed with the implementation of EPAs and an e-portfolio, based on these 4 principles. The authors found that the revised curriculum corresponds to daily practice in clerkships. Students used their e-portfolios throughout all clerkships, which stimulates feedback-seeking behavior. Moreover, EPAs promote continuity in learning while rotating clerkships every 1 to 2 months. This might encourage curriculum developers to use EPAs when aiming for greater continuity in the development of students. Future research needs to focus on the effect of EPAs on transitions across clerkships in order to further improve the undergraduate medical curriculum.

Crossroads experiences for promoting self-authorship of clinical medical students: A qualitative survey

BACKGROUND

The capacity of self-authoring one's own beliefs, identity, and relationships is core to many expected outcomes of future health-care professionals. Students' personal and professional development for self-authorship can be promoted by the variety of developmentally effective "crossroads" experiences that they encounter. Identifying the characteristics of the crossroads experiences in clinical rotations can provide a foundation for medical educators to provide an environment that can foster self-authorship.

MATERIALS AND METHODS

A cross-sectional qualitative survey was conducted using a researcher developed semi-structured questionnaire which had three open questions and asked medical interns to describe their internship experiences that stimulated their thinking along the self-authorship dimensions of identity, relationships, and ways of knowledge acquisition. Data were analyzed using Braun and Clarkes' thematic analysis method.

RESULTS

The survey was completed by 167 medical interns (response rate: 83%). The key features of significant crossroads experiences and their effects were created into six themes: Experiences by being respected and validated; experiences by involvement in patient management; experiences by participation in interactive learning environments; experiences by participation in authentic clinical work environments; experiences by the observation of professional behaviors; experiences through the uniqueness of different specialties.

CONCLUSION

Authentic experiences of patient management in the real world of clinical settings with a high interactive environment have the potential to promote interns' self-authorship development. Educators can support learners by respecting and validating their capacities and by role modeling of professional behaviors.

Associations of university student life challenges with mental health and self-rated health: A longitudinal study with 6 months follow-up

BACKGROUND

Mental health problems are highly prevalent among university students. Stress due to student life challenges may be a risk factor for poorer health. This study investigates to what extent student life challenges and changes therein are associated with mental health and self-rated health.

METHODS

In a longitudinal study with 568 Italian university students mental health was assessed using the Mental Health Inventory-5 (MHI-5) and self-rated health with a single item from the Short Form 36 Health Survey (SF36) (score ranges: 0-100) at baseline and at six months follow-up. Student life challenges were investigated using six subscales (score ranges: 1-4) of the Higher Education Stress Inventory (HESI). A between-within linear regression model was used to investigate whether a higher exposure to life challenges was associated with poorer health (between individuals) and whether changes in student life challenges were associated with changes in health (within individuals).

RESULTS

Higher exposure to student life challenges was associated with poorer mental health (b ranging from -5.3 to -10.3) and self-rated health (b ranging from -3.1 to -9.6). An increase in student life challenges within individuals was associated with poorer mental health and self-rated health, in particular for high workload (b up to -5.9), faculty shortcomings (b up to -5.7), and unsupportive climate (b up to -5.6).

DISCUSSION

Exposure to student life challenges and changes therein are associated with university students' health. Our findings suggest that student life challenges may be a target for interventions to improve mental health and self-rated health among university students.

Medical student perceptions of curricular influences on their wellbeing: a qualitative study

BACKGROUND

Medical student mental health and wellbeing is highly topical and the subject of much research. While theoretically informed definitions of wellbeing abound, how do medical students themselves understand and perceive wellbeing? What aspects of the curriculum do they regard as affecting their wellbeing and mental health? This study explored these questions, and aimed to identify factors associated with student acceptability of wellbeing programs and interventions.

METHODS

All students at an Australian undergraduate medical school (n = 619) were invited to complete a qualitative online questionnaire between 2017 and 2018 following the introduction of several wellbeing initiatives, including "Wellbeing Days" (WBD). WBD allow students to take single absence days for self-care. Open-ended questions were asked about perceptions and experience of mental health and wellbeing, and views on interventions to improve wellbeing such as WBD. Thematic analysis was conducted across all responses. Three authors developed preliminary themes, which were then refined and confirmed by all researchers. Thematic saturation was achieved within data from the 68 respondents, which included participants from all cohorts.

RESULTS

Participants described wellbeing as positively experienced work/life balance, impacted by four factors; contact hours, peer relationships, staff relationships, and trust in how wellbeing initiatives were used. Long contact hours were deemed incompatible with self-care activities, maintaining employment, and seeking professional medical/psychological help. Peers could promote wellbeing by offering social and academic support, but also undermine wellbeing by being competitors. Degree of trust, engagement and communication with staff influenced acceptability of interventions. Participants viewed initiatives such as WBD favourably, but distrust of peers, and of staff, led to perceptions that WBD could be prone to misuse, or used for surveillance rather than support.

CONCLUSION

Our findings suggest that wellbeing days which allow self-care, reduction in contact hours, and peer support may promote student wellbeing, but the acceptability of any interventions is influenced by relationships between staff and students, and in particular, trust in these relationships. We suggest strategies to strengthen trust and further research to investigate the relationship between trust and perceptions of wellbeing in self and peers.