A model of influences on the clinical learning environment: the case for change at one U.S. medical school

Feedback in family medicine clerkships: a qualitative interview study of stakeholders in community-based teaching

Feedback is an important aspect of teaching and learning in medical education. Irrespective of the training environment, too little effective dialogic feedback occurs. Community-based outpatient learning environments, such as general practitioner practices, have heterogeneous framework conditions regarding feedback that decrease feedback quality. To improve feedback in this setting, characteristics of feedback in such learning environments must be considered. This study aims to reveal such characteristics from different perspectives and derive ideas for improving feedback in community-based learning environments. Three stakeholder groups in family medicine clerkships as an example of community-based learning environments (n = 15 students, n = 12 faculty and administrative staff, n = 13 general physician trainers) were interviewed for this study. Transcripts of the interviews were analysed with qualitative content analysis. All stakeholders interviewed note a lack of feedback between groups. Feedback in primary care practices takes place in specific contexts (e.g., during vs after a consultation, during vs at the end of the clerkship) and is provided in different ways (e.g., verbal vs nonverbal). Barriers of effective feedback in community-based settings are: lack of opportunity/initiation, fear of giving feedback, unawareness (of correct feedback and/or lack of prior experience with feedback), and little basis for feedback. Currently, the exchange between the university and community-based learning environments is limited to grading and report writing, with little sharing of meaningful information. The potential of a better exchange between those within community-based learning environments and the university to improve feedback processes is not reached. This exchange and the framework conditions specific for the community-based learning environment should be considered as parts of the structural dimension of feedback. Teachers and course managers of family medicine institutes are in an important position to shape these factors actively, working together with stakeholders of community-based teaching.

The Role of Transformational Leadership on Firm Performance: Mediating Effect of Corporate Sustainability and Moderating Effect of Knowledge-Sharing

The primary purpose of the research is to investigate the mediating role of corporate sustainability in the relationship between the impacts of transformational leadership on the performance of firms. This study also aimed to investigate the moderating role of knowledge-sharing on the relationship of transformational leadership with corporate sustainability. Respondents of the study were the top management of large Chinese automobile sectors, such as Shanghai Automotive Business Corporation (Group), China FAW Group Corporation, Dongfeng Motor Co., Ltd., Beijing Automotive Group Co., Ltd., and China North Industries Group Corporation. These are the companies with the biggest market share in the automobile manufacturing industry in China. The data was gathered by using a self-administrative survey questionnaire from 198 individuals operating in different automobile industries in different sectors of China. The data were analyzed using structural equation modeling (SEM) through the Smart PLS 3.3.2 software. The results of this study revealed that transformational leadership has a positive and significant effect on the performance of the firm. Corporate sustainability has a significant positive mediating role in the association of transformational leadership and firm performance. Findings indicated that knowledge-sharing also has a positive moderating role in the association between transformational leadership and firm performance. The findings of this study contribute to the body of knowledge and show that leadership style has a significant effect on firm performance and that knowledge-sharing culture in firms is essential for better performance of the firm. Furthermore, firms may improve their performance by improving their sustainability and by creating knowledge-sharing culture. The findings are important, particularly in connection with a developed country like China. The findings have important insights for various stakeholders, i.e., government, regulatory bodies, practitioners, academia, industry, and researchers.

Are we prepared for the future? A mixed-method study on quality management in decentralized family medicine teaching

In Germany, two-week clinical clerkships in university-associated general practices have existed since 2002. Approximately 10,000 medical students participate in these decentral clerkships each year. Empirical information on quality management strategies in decentral learning environments is sparse. This nationwide study aims to describe the current quality management efforts of German family medicine departments in response to negative events. A nationwide three-part mixed methods study on the quality management of family medicine clerkships was conducted. First, individuals from n = 37 family medicine departments involved in the organization of family medicine clerkships were interviewed. Interview transcripts were analyzed with qualitative content analysis. Second, a questionnaire on quality management of decentralized learning environments based on the categories of the analysis was developed and sent to the departments. Three negative event cases in family medicine clerkships were included in the questionnaire. Third, interview and survey data were integrated based on respondents' process descriptions of how each department handled the cases. Of the 37 contacted departments, n = 12 (32%) performed an interview. Major categories of negative events included problems in the student-teacher interaction, didactical challenges, and problematic student behavior. Twenty departments answered at least one questionnaire (54%). Most respondents indicated that their department conducts quality management in decentralized teaching. Negative events in decentral family medicine clerkships occurred at a rate of 66.4 to 179.5 events per 10.000 Students per semester. The mixed-method analysis showed that departments are conscious about quality management issues in decentral learning environments but adhere to heterogeneous local standards. Negative events occur regularly in decentral learning environments. Local quality management processes exist but lack national harmonization. Further outcome-based research is needed to explore the effectiveness and feasibility of quality management strategies. This will become increasingly relevant with an expected upscaled family medicine content.

You Too? Female Radiologists' Narratives on Discrimination and Harassment

BACKGROUND

There is a paucity of examples for gender discrimination and sexual harassment in radiology. This lack of knowledge can limit radiologists' ability to relate to this topic, acknowledge its importance and impact, and take actions toward improvement.

MATERIALS AND METHODS

We conducted a qualitative analysis using the model of thematic analysis developed by Braun and Clarke of narrative responses to a survey on the topic of #MeToo, which was distributed to a social media group of female radiologists.

RESULTS

In all, 575 anonymous survey responses from 3,265 social media group members were analyzed. Among these responses, the study team identified important themes with examples, including Victims and Perpetrators, Acts of Gender Discrimination, Inequalities, Sexual Harassment and Assault, and Microaggressions.

CONCLUSION

The narratives provide relatable examples of gender discrimination and sexual harassment in radiology. These may spark discussions that raise awareness among radiologists and result in interventions geared toward improvement.

'What a Pretty Assistant You Have': Addressing Sex-Based Harassment by Patient Offenders in Undergraduate Medical Training

Sex-based harassment remains a concern in the medical workplace environment and is negatively associated with physical and mental health complications. Presently, undergraduate medical education fails to provide students with the appropriate toolset to successfully handle sex-based harassment by patient offenders. Through peer discussion and personal experience from a medical student perspective, herein we suggest strategies for individuals at all levels of medical training to help mitigate these uncomfortable situations. Simulation-based training and implementation of frameworks regarding microaggressions are crucial components of the medical curricula which must be incorporated expediently to create cultural change and help combat pre-existing historical precedents.

Interventions promoting employee "speaking-up" within healthcare workplaces: A systematic narrative review of the international literature

BACKGROUND

Healthcare systems worldwide increasingly value the contribution of employee voice in ensuring the quality of patient care. Although employees' concerns are often dealt with satisfactorily, considerable evidence suggests that some employees may feel unable to speak-up, and even when they do their concerns may be ignored. As a result, in addition to trans-national and national policies, workplace interventions that support employees to speak-up about their concerns have recently increased.

METHODS

A systematic narrative review, informed by complex systems perspectives addresses the question: "What workplace strategies and/or interventions have been implemented to promote speaking-up by employees"?

RESULTS

Thirty-four studies were included in the review. Most studies reported inconclusive results. Researchers explanations for the successful implementation, or otherwise, of speak-up interventions were synthesised into two narrative themes (Braithwaite et al., 2018 (a)) hierarchical, interdisciplinary and cultural relationships and (Francis, 2015 (b)) psychological safety.

CONCLUSIONS

We strengthen the existing evidence base by providing an in-depth critique of the complex system factors influencing the implementation of speak-up interventions within the healthcare workforce. Although many of the studies were locally unique, there were international similarities in workplace cultures and norms that created contexts inimical to speaking-up interventions. Changing communication behaviours and creating a climate that supports speaking-up is immensely challenging. Interventions can be usurped in practice by complex, emergent and contextual issues, such as pre-existing socio-cultural relationships and workplace hierarchies.

More Than Words: A Vision to Address Bias and Reduce Discrimination in the Health Professions Learning Environment

Bias and discrimination are embedded within the history, norms, and practices of the health professions institution, and their negative impacts are pervasive in the health professions learning environment. These forces impair the ability to take care of patients, recruit and support diverse health care providers, and prepare the next generation of clinicians for practice. Fortunately, there are effective interventions and strategies for addressing bias and discrimination within learning environments and to both prevent and ameliorate their negative effects. This Perspective lays out a vision for health professions learning environments that are free from bias and discrimination and makes 5 recommendations, with supporting actions, that will help the leaders of health care institutions achieve this goal.

Ending student mistreatment: early successes and continuing challenges

Problem: Student mistreatment represents an ongoing challenge for US medical schools. Students experiencing mistreatment may become marginalized and cynical, and they have higher rates of burnout, depression and substance use disorders. Although numerous attempts to eliminate mistreatment have been proposed, best practices remain elusive. We formed a unique student-faculty collaboration (the Ending Mistreatment Task Force) that allowed all voices to be heard and enabled identification of five interventions to reduce mistreatment.Intervention: The EMTF developed and implemented five key interventions: 1) a shared mistreatment definition; 2) measures to increase faculty accountability, including adding professionalism expectations to faculty members' contracts and performance reviews; 3) a Professionalism Office to respond promptly to students' reports of mistreatment and provide feedback to faculty; 4) tools to help teachers provide authentic learning environments for students, while addressing generational misunderstandings; and 5) student-produced videos, helping faculty understand the impact of mistreatment as seen through students' eyes.Context: These interventions occurred at one medical school where mistreatment reports were consistently above national averages.Impact: Over 6 years, the interventions helped reduce the rate of student-reported mistreatment by 36% compared with a 4% decline across all US medical schools.Lessons: The collaborations between students and faculty helped each party identify unexpected misunderstandings and challenges. We learned that students want hard questions, although faculty are often afraid to challenge students for fear of offending them or being reported. We clarified differences between mistreatment and sub-optimal learning environments and openly discussed the pervasive opinion that 'some' mistreatment is important for learning. We also identified ongoing challenges, including the need to solicit residents' perspectives regarding mistreatment and develop proper responses to disrespectful comments directed at patients, family and colleagues. The collaboration reinforced students' and faculty members' shared commitment to upholding a respectful learning and clinical care environment and ending mistreatment.

Medical students' perception of behaviors in the clinical learning environment evolve with increasing clinical exposure as measured with situational video vignettes

This cross-sectional study involved matriculating, mid-level and graduating medical students (n = 723) who participated in specific transition courses in our medical school curriculum between August 2016 and March 2019. We used a mixed-methods approach (survey and analysis of narrative comments) to study the evolution in perception of the learning environment by medical students with increasing clinical exposure using four different video vignettes. Differences in student perceptions of mistreatment exists at various levels of training. Compared to graduating students, matriculating students were more likely to perceive reprimanding a student on being late as appropriate behavior (80.5% vs 53.3%, p = 0.001), whereas a significantly higher proportion of the graduating students (15.3%, p = 0.001) perceived it as mistreatment. A majority of the matriculating students (84%, p = 0.001) considered the case of an eager student as mistreatment, while a significantly higher proportion of the graduating students (59.5%, p = 0.001) did not think it was mistreatment. Qualitative analysis of comments from students at different stages of training displayed an increased appreciation of their professional responsibilities and nuanced appreciation of body language and tone as contributing factors in determining whether a situation represented inappropriate behavior. Our results demonstrate that students' perceptions of inappropriate behaviors evolve with increased clinical exposure.

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

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

Benchmarking the Physical Therapist Academic Environment to Understand the Student Experience

BACKGROUND

Identifying excellence in physical therapist academic environments is complicated by the lack of nationally available benchmarking data.

OBJECTIVE

The objective of this study was to compare a physical therapist academic environment to another health care profession (medicine) academic environment using the Association of American Medical Colleges Graduation Questionnaire (GQ) survey.

DESIGN

The design consisted of longitudinal benchmarking.

METHODS

Between 2009 and 2017, the GQ was administered to graduates of a physical therapist education program (Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa [PTRS]). Their ratings of the educational environment were compared to nationwide data for a peer health care profession (medicine) educational environment. Benchmarking to the GQ capitalizes on a large, psychometrically validated database of academic domains that may be broadly applicable to health care education. The GQ captures critical information about the student experience (eg, faculty professionalism, burnout, student mistreatment) that can be used to characterize the educational environment. This study hypothesized that the ratings provided by 9 consecutive cohorts of PTRS students (n = 316) would reveal educational environment differences from academic medical education.

RESULTS

PTRS students reported significantly higher ratings of the educational emotional climate and student-faculty interactions than medical students. PTRS and medical students did not differ on ratings of empathy and tolerance for ambiguity. PTRS students reported significantly lower ratings of burnout than medical students. PTRS students descriptively reported observing greater faculty professionalism and experiencing less mistreatment than medical students.

LIMITATIONS

The generalizability of these findings to other physical therapist education environments has not been established.

CONCLUSIONS

Selected elements of the GQ survey revealed differences in the educational environments experienced by physical therapist students and medical students. All physical therapist academic programs should adopt a universal method to benchmark the educational environment to understand the student experience.

Assessment of Programs Aimed to Decrease or Prevent Mistreatment of Medical Trainees

IMPORTANCE

Mistreatment of medical students is pervasive and has negative effects on performance, well-being, and patient care.

OBJECTIVE

To document the published programmatic and curricular attempts to decrease the incidence of mistreatment.

DATA SOURCES

PubMed, Scopus, ERIC, the Cochrane Library, PsycINFO, and MedEdPORTAL were searched. Comprehensive searches were run on "mistreatment" and "abuse of medical trainees" on all peer-reviewed publications until November 1, 2017.

STUDY SELECTION

Citations were reviewed for descriptions of programs to decrease the incidence of mistreatment in a medical school or hospital with program evaluation data. A mistreatment program was defined as an educational effort to reduce the abuse, mistreatment, harassment, or discrimination of trainees. Studies of the incidence of mistreatment without description of a program, references to a mistreatment program without outcome data, or a program that has never been implemented were excluded.

DATA EXTRACTION AND SYNTHESIS

Authors independently reviewed all retrieved citations. Articles that any author found to meet inclusion criteria were included in a full-text review. The data extraction form was developed based on the guidelines for Best Evidence in Medical Education. An assessment of the study quality was conducted using a conceptual framework of 6 elements essential to the reporting of experimental studies in medical education.

MAIN OUTCOMES AND MEASURES

A descriptive review of the interventions and outcomes is presented along with an analysis of the methodological quality of the studies. A separate review of the MedEdPORTAL mistreatment curricula was conducted.

RESULTS

Of 3347 citations identified, 10 studies met inclusion criteria. Of the programs included in the 10 studies, all were implemented in academic medical centers. Seven programs were in the United States, 1 in Canada, 1 in the United Kingdom, and 1 in Australia. The most common format was a combination of lectures, workshops, and seminars over a variable time period. Overall, quality of included studies was low and only 1 study included a conceptual framework. Outcomes were most often limited to participant survey data. The program outcome evaluations consisted primarily of surveys and reports of mistreatment. All of the included studies evaluated participant satisfaction, which was mostly qualitative. Seven studies also included the frequency of mistreatment reports; either surveys to assess perception of the frequency of mistreatment or the frequency of reports via official reporting channels. Five mistreatment program curricula from MedEdPORTAL were also identified; of these, only 2 presented outcome data.

CONCLUSIONS AND RELEVANCE

There are very few published programs attempting to address mistreatment of medical trainees. This review identifies a gap in the literature and provides advice for reporting on mistreatment programs.

Tracking Student Mistreatment Data to Improve the Emergency Medicine Clerkship Learning Environment

Introduction

Medical student mistreatment is a prevalent and significant challenge for medical schools across the country, associated with negative emotional and professional consequences for students. The Association of American Medical Colleges and Liaison Committee on Medical Education have increasingly emphasized the issue of mistreatment in recent years, and medical schools are tasked with creating a positive learning climate.

Methods

The authors describe the efforts of an emergency department (ED) to improve its clerkship learning environment, using a multifaceted approach for collecting mistreatment data and relaying them to educators and clerkship leadership. Data are gathered through end-of-rotation evaluations, teaching evaluations, and an online reporting system available to medical students. Mistreatment data are then relayed to the ED during semi-annual meetings between clerkship leadership and medical school assistant deans, and through annual mistreatment reports provided to department chairs.

Results

Over a two-year period, students submitted a total of 56 narrative comments related to mistreatment or unprofessional behavior during their emergency medicine (EM) clerkship. Of these comments, 12 were submitted in 2015-16 and 44 were submitted in 2016-17. The most frequently observed themes were students feeling ignored or marginalized by faculty (14 comments); students being prevented from speaking or working with patients and/or attending faculty (11 comments); and students being treated in an unprofessional manner by staff (other than faculty, 8 comments).

Conclusion

This article details an ED's efforts to improve its EM clerkship learning environment by tracking mistreatment data and intentionally communicating the results to educators and clerkship leadership. Continued mistreatment data collection and faculty development will be necessary for these efforts to have a measurable effect on the learning environment.

Case Studies for Recognizing Appropriate and Inappropriate Behaviors in the Clinical Learning Environment

INTRODUCTION

The Association of American Medical Colleges surveys graduating medical students regarding the persistent prevalence of learning environment concerns. This training module is designed to increase awareness of appropriate and inappropriate behaviors in the clinical learning environment among medical professionals and trainees.

METHODS

An introductory PowerPoint presents the types of inappropriate behaviors that may be observed in the clinical learning environment along with institution-specific mechanisms for reporting such behaviors. We have also created six vignettes depicting various scenarios that trainees may encounter. The vignettes are presented in both text and video format and may be used in any combination. The entire module consisting of the PowerPoint presentation and the case studies can be delivered in 90 minutes to a large group of learners. Learners are divided into smaller groups of six to eight for discussions. The presentation and discussion can be done by a single or multiple facilitators. The target audience is primarily medical professionals and trainees at various levels of clinical exposure.

RESULTS

Since implementation of this training module at our institution, awareness of what constitutes mistreatment and how to report it has increased to nearly 100%. Representative institutional responses are provided for each vignette.

DISCUSSION

This training module can be presented to medical students, residents, and faculty at different stages of their professional development. We have enhanced learner awareness of what constitutes mistreatment and how to report these events. We offer these educational materials for other institutions to adapt and use in their specific institutional contexts.