Feedback Culture Perceived by Trainees in an Academic Institution: A Mixed Methods Study

OBJECTIVES

Lack of a well-functioning institutional feedback culture can undermine acquisition of skills essential for high quality patient care. The objective of this study was to assess feedback culture perceived by resident and fellow trainees, utilizing a mixed methods design.

METHODS

Pediatric fellows and residents completed an anonymous feedback environment survey consisting of 7 constructs: source credibility, feedback quality, feedback delivery, reinforcing feedback, constructive feedback, source availability, and promotion of feedback seeking, using a 7-point Likert scale. Trainee ratings were compared using two-sided Fisher's exact tests. Multivariable analyses used a linear regression model. For the qualitative study, semistructured interviews of residents were conducted. The constant comparative method was used to incrementally code, categorize data, and derive themes.

RESULTS

Fifty-two residents and 21 fellows completed the survey (response rates 65% and 47%, respectively). Scores were more favorable for fellows compared with residents in 6 of 7 feedback constructs (P < .05), including on multivariate analysis. Hispanic ethnicity and female gender were associated with lower scores on source credibility (P = .04) and constructive feedback (P = .03), respectively. Two qualitative themes were identified: expectation of efficiency in patient care compromises the quality and quantity of feedback, and a culture that prioritizes courtesy over candor negatively impacts feedback quality. These themes were more pronounced when residents worked with pediatric subspecialists compared with hospitalists.

CONCLUSIONS

We described the feedback culture, which was less favorable in the residency program. The need for efficient patient care and a culture of courtesy adversely impacted the quality of feedback, especially among subspecialists.

Variation in medical humanities program mission statements in United States and Canadian Medical Schools

PURPOSE

In 2019, the American Association of Medical Colleges (AAMC) identified the discipline of medical humanities as a priority in medical education. Although medical humanities programs have existed in medical and osteopathic schools in the U.S. and Canada since the late 1960's, this interdisciplinary field remains difficult to define. We studied the mission statements of medical humanities programs to identify core themes and priorities.

MATERIALS AND METHODS

We conducted a content analysis of U.S. and Canada medical humanities MD and DO mission statements and associated descriptions (n = 56). We compared themes across programs whose directors had a clinical degree versus a terminal research degree, conducted comparisons between medical humanities programs housed in medical schools ranked in Top 20 U.S. News and World Report for Research or Primary Care, and conducted a word frequency analysis.

RESULTS

Content analysis revealed five themes: improving patient care, improving the provider experience, generating scholarship, cultivating community relationships, and promoting diversity/sociocultural awareness. 70% of programs emphasized patient care and provider experience. Only 34% included the promotion of diversity/sociocultural awareness as a theme. Word frequency analysis corroborated our findings.

CONCLUSIONS

U.S. and Canada medical humanities programs focus primarily on improving patient care and provider wellness.

Multifaceted Approach to Evaluation in a Pediatric and Adolescent Gynecology Rotation for Medical Students

STUDY OBJECTIVE

We evaluated whether and to what extent a novel medical student rotation in pediatric and adolescent gynecology (PAG) increases clinical knowledge and skills and meets student needs and expectations.

DESIGN

Constructivist prospective pre-post study and post-rotation student survey SETTING: Academic medical center PARTICIPANTS: Pilot study of 9 medical students, which represents the entire population of those who completed the rotation.

INTERVENTIONS

Four-week clinical rotation in PAG MAIN OUTCOME MEASURES: Changes in clinical knowledge were measured by a pre- and post-intervention multiple-choice assessment, and clinical skills were assessed before and after the intervention using entrustable professional activities (EPAs); these data were analyzed with paired Student's t tests. Student evaluations of the rotation were measured through an anonymous, end-of-rotation, closed- and open-ended survey and were analyzed using descriptive statistics.

RESULTS

A statistically significant increase in clinical knowledge was observed post-rotation, with a mean pretest score of 67.0% (standard deviation [SD] 1.7%) and a mean posttest score of 75.2% (SD 3.2%, P = 0.02). Statistically significant increases were observed for all EPAs between the first and final day of the rotation. Eight students who completed the post-rotation survey rated the rotation favorably (5 on a scale from 1 to 5).

CONCLUSION

A multipronged evaluation showed that a new PAG clinical rotation significantly increased medical students' clinical skills and knowledge. This multifaceted evaluation method provides valuable insights to educators on how best to tailor a rotation to individual learners' levels of clinical skills and knowledge. If comparable rotations could be instituted and similarly evaluated in other medical schools, a noticeable knowledge/skill gap among trainees might be addressed.

Thriving in Neurology Residency: An Appreciative Inquiry Approach

BACKGROUND AND OBJECTIVES

Enhancing resident well-being has become a top priority for medical educators as awareness of physician burnout continues to grow. Though significant effort has been made to understand contributors to resident burnout and develop effective interventions, relatively little is known about what characterizes the opposite of burnout, i.e., thriving in medical training. This phenomenological qualitative study applies Appreciative Inquiry as an interview technique with the aim of characterizing self-identified experiences of thriving among residents in the Yale Neurology program.

METHODS

Eight residents across all years of training in a single neurology residency participated in semi-structured appreciative interviews to identify experiences of thriving during neurology training. These interviews were transcribed and qualitatively analyzed with a phenomenologic perspective for common themes.

RESULTS

Numerous themes emerged spanning personal, interpersonal, and organizational domains. While some of these themes were congruent with established foundations of well-being and adult learning theory, others revealed the crucial contributions of stress and challenge to thriving. One of the strongest emergent themes was the tendency of residents to thrive during autonomous, high-challenge, high-stress situations, provided that adequate support was present and psychological safety was ensured.

DISCUSSION

These findings resonate with phenomena studied in positive psychology that are not currently being widely applied in medical education. To the degree conclusions are transferable to other training contexts, this study suggests an opportunity for medical educators to harness the positive aspects of stress and challenge in a supportive way that facilitates trainee well-being through experiences of thriving.

Perspectives on the Effectiveness of a Medical Futility Policy

BACKGROUND

The principal aim of this study was to investigate the function and effectiveness of an institutional policy that outlines a procedure to limit medically futile interventions. We were interested in the attitudes and opinions of careproviders and the members of the Yale New Haven Hospital Ethics Committee that use this policy, the Conscientious Practice Policy (CPP), to address questions on appropriate interventions in the setting of medical futility.

METHODS

In 2019, we conducted three focus groups of members of the Yale New Haven Hospital Ethics Committee and critical care physicians, asking participants questions concerning their use of the Yale New Haven Hospital's policy on limiting futile interventions. Focus group transcript results were coded into common themes using a conventional analysis approach.

RESULTS

The overarching finding was that the CPP had various levels of interpretation that prevented its effective and consistent use. This was supported by the four main themes from the focus groups: (1) Mixed perceptions regarding communication between careproviders and family members and surrogates before the CPP was invoked contributed to complexity in decision making. (2) It was ineffective to use an ethics consultation to decide whether or not to invoke the CPP. (3) It was necessary to address moral distress in the absence of a policy. (4) The use of the CPP was inconsistent for different patients, based on the degree to which family members and surrogates persisted in their resistance to limiting medically futile interventions, careproviders' comfort with directly making decisions, and bias towards members of certain groups.

CONCLUSION

The CPP, as it has been used at the Yale New Haven Hospital, has been ineffective in rationally, fairly, and consistently resolving conflicts regarding the appropriateness of ending medically futile interventions. The CPP, as well as similar policies at other institutions, may benefit from restructuring the policy to more closely align with policies at other institutions where outcomes have been more successful.

Are Internal Medicine Residents Meeting the Bar? Comparing Resident Knowledge and Self-Efficacy to Published Palliative Care Competencies

Background:

There is a need for improved primary palliative care (PC) education and resident comfort with providing end-of-life care.

Objective:

Utilize a new instrument derived from published PC competencies to assess baseline Internal Medicine (IM) resident knowledge and self-efficacy in PC to identify educational gaps and create new PC curricula.

Design:

We created a 2-part instrument including a Knowledge Test (KT) and a Self-Efficacy Inventory (SEI) addressing 18 PC resident competencies across 5 domains: Pain and Symptom Management (PSM), Communication (COMM), Psychosocial, Spiritual, and Cultural Aspects of Care (PSC), Terminal Care and Bereavement (TCB), and Palliative Care Principles and Practice (PCPP).

Setting/Subjects:

The instrument was emailed to IM residents at our institution during academic years 2015-2016 and 2016-2017.

Measurements:

Basic descriptive statistics were performed for the KT and SEI. Mean Rank Analysis and One-way ANOVA were utilized for the KT and SEI, respectively. Congruence was calculated between knowledge and self-efficacy.

Results:

The mean score on the KT was 73% (range 33-80%). There was no significant difference in knowledge among post-graduate year cohorts. Self-efficacy scores were lower for interns overall and in PCPP, TCB, and COMM domains. Knowledge was concordant with self-efficacy in 42% of participants, higher than self-efficacy in 10% of participants, and lower than self-efficacy in 48% of participants.

Conclusions:

For approximately half of respondents, high self-efficacy in PC did not correlate with high PC knowledge. A more focused curriculum is needed to help IM residents facilitate mastery of PC competencies by graduation.

Burnout Among Beginning First-Year Students from Three Health Professional Training Programs

The study objective was to learn about burnout prevalence among beginning first-year students from three health professional programs-Advance Practice Registered Nursing (APRN), Medicine, and Physician Associate (PA) training. All first-year students were invited to anonymously complete a survey measuring burnout. Subscales for exhaustion and disengagement together accounted for burnout. Means and frequencies were derived for categorical variables (gender, program, and direct entry from college). Subscales were summarized with means and standard deviations. Analysis of variance and post hoc t-tests compared unadjusted differences in means. Based on results, multivariable linear regressions for total burnout and exhaustion examined associations for the independent variables. With a 97% response rate, 70% were female (the APRN program is predominantly female), and 32% began training directly after college. Female students had significantly higher average total burnout and exhaustion than males. APRN and PA students had significantly higher total burnout and exhaustion than MD students. There were no other significant associations. In multivariable linear regressions, APRN students had significantly higher, and PA students had not quite significantly higher, burnout and exhaustion compared with medical students, with no moderation by any other variables. Burnout among first-year students in all three programs was more prevalent than anticipated. Consistent with previous literature, the programs with students who experienced higher burnout used more competitive, multi-tiered grading systems and introduced clinical expectations earlier in training. The implication is that educational leaders should consider effects of competitive grading and early clinical exposure on burnout among beginning health professional students.

Establishing a Pediatric and Adolescent Gynecology Subinternship for Medical Students

Within the pediatric and adolescent gynecology (PAG) community, an important issue deserving of our attention is expansion of formalized PAG training opportunities for medical students. In addition to those in obstetrics and gynecology, many physicians practicing family medicine, internal medicine, and surgery provide care to young female patients. However, residency programs provide inconsistent training in addressing specific PAG health care needs and communication skills required for delivery of care to pediatric and adolescent patients; opportunities for supervised clinical experience in these areas at the medical school level therefore have great importance because they might not be offered again during some residencies. At the undergraduate medical education level, training opportunities in PAG are currently limited, with only 3 PAG subinternships in North American medical schools. In contrast, other available subinternships include 113 in maternal fetal medicine and 82 in gynecologic oncology. To address this gap in opportunities for medical students, we developed a PAG subinternship and elective for medical students, which we describe in this report. Our 4-week PAG subinternship and 2-week elective expose students to a variety of ambulatory and surgical opportunities, with formal, informal, and self-guided learning activities. In this article, we explain the process of developing the curriculum, gaining alignment from key stakeholders, obtaining formal approval for the course, and advertising the opportunity to medical students. We also provide resources and guidance for medical educators who wish to establish a PAG subinternship or elective course at their institutions.

Pediatric Residents' Beliefs and Behaviors About Health Care for Sexual and Gender Minority Youth

Little is known about provider beliefs related to sexual and gender minority (SGM) youth, and how these have changed over time. Our objective was to compare pediatric residents' beliefs and behaviors about SGM youth to historical data. Forty-eight of 76 (63%) residents completed a survey of items drawn from 2 existing scales. Results were compared with historical data from 1998 to 2012. Compared to historical respondents, residents indicated that they were significantly more likely to take a sexual history from patients under 14 years old and ask about sexual orientation. Residents were significantly less likely to fear offending parents or patients with such discussions. While responses indicated SGM-affirming beliefs, 45% of residents felt they may not know enough about SGM needs to have effective discussions, similar to historical respondents. Ongoing challenges include a perceived lack of knowledge about the needs of SGM youth, representing avenues for future educational intervention.

A novel near-peer reflective writing workshop

BACKGROUND

Training in clinical medicine involves exposure to complex ethical and emotional situations. Reflection aids in the development of personal belief systems and improves self-awareness. Students may be reluctant to participate when reflection is mandatory and may be concerned about retaliation when the facilitator has a role in evaluations. Near-peers are institutional equals with more experience than the participants and may be well suited to facilitate reflection.

METHODS

A quarterly near-peer-facilitated reflective writing workshop (RWW) was implemented in the mandatory clinical curriculum at a single institution. Qualitative feedback forms were solicited and were analysed through an iterative and inductive consensus process. An end-of-year web-based survey was distributed to test the hypotheses generated from our analysis of the feedback forms.

RESULTS

There were 82 responses (80%) to the web-based survey and 266 (65%) feedback forms were collected. Although few students reported using writing as a coping mechanism, the RWW was viewed favourably, with 62% indicating that they would attend if optional. The structured prompts aided reflection. Students reported a higher likelihood of discussing difficult topics (doubts about medicine as a career, personal shortcomings, harassment and burnout) in sessions led by a near-peer than by a faculty member. The workshop created a safe space to reflect, increased a sense of camaraderie and helped normalise experiences. [The workshop] humanised the clinical experience, gave new perspective and reminded students of their positive personal accomplishments DISCUSSION: The near-peer-facilitated RWW is a novel intervention aimed at developing reflective practice and coping with the challenges of entering clinical medicine. It is highly structured and has been incorporated into the mandatory curriculum. It was well received by students, is generalisable and is easily implementable.

A New Competency-Based Instrument to Assess Resident Knowledge and Self-Efficacy in Primary Palliative Care

CONTEXT

There is a need to improve both primary palliative care (PPC) education and its assessment in graduate medical education (GME). We developed an instrument based on published palliative care (PC) competencies to assess resident competency and educational interventions.

OBJECTIVES

To describe the development and psychometric properties of a novel, competency-based instrument to measure resident knowledge and self-efficacy in PPC.

METHODS

We created a 2-part instrument comprised of a knowledge test (KT) and a self-efficacy inventory (SEI) addressing 18 consensus, core PC resident competencies across 5 domains: pain and symptom management; communication; psychosocial, spiritual, and cultural aspects of care; terminal care and bereavement; and PC principles and practice. The instrument was distributed to 341 internal medicine residents during academic years 2015 to 2016 and 2016 to 2017. A standard item analysis was performed on the KT. Internal consistency (Cronbach α) and variable relationships (factor analysis) were measured for the SEI.

RESULTS

One hundred forty-four residents completed the survey (42% response). For 15 KT items, difficulty ranged from 0.17 to 0.98, with 7 items ranging 0.20 to 0.80 (typical optimum difficulty); discrimination ranged from 0.03 to 0.60 with 10 items ≥0.27 (good to very good discrimination). Cronbach α was 0.954 for 35 SEI items. Factor analysis of combined 2015 to 2016 items yielded 4 factors explaining the majority of variance for the entire set of variables.

CONCLUSION

Our instrument demonstrates promising psychometric properties and reliability in probing the constructs of PC and can be further utilized in PC GME research to assess learners and evaluate PPC educational interventions.

Principles and Practices for Developing an Integrated Medical School Curricular Sequence About Sexual and Gender Minority Health

Problem: Sexual and gender minority patients face well-documented health disparities. One strategy to help overcome disparities is preparing medical trainees to competently provide care for sexual and gender minority patients. The Association of American Medical Colleges has identified professional competencies that medical students should develop to meet sexual and gender minority health needs. However, challenges in the medical education environment may hinder the adoption and implementation of curricular interventions to foster these competencies. Intervention: Our medical education community engaged in curriculum evaluation and subsequently developed a sexual and gender minority topical sequence to promote student development of these competencies. This process was guided by explicit principles and curriculum development practices. Context: This work began at the Yale University School of Medicine in 2014, shortly after the Association of American Medical Colleges published sexual and gender minority health competencies and amidst the development and implementation of a new curriculum at the institution. Impact: We identified core principles and practices to guide the development of an integrated sexual and gender minority health sequence. This process resulted in successful creation of an integrated curricular sequence. At this time, 9 new or enhanced curricular components have been adopted through our process-5 in preclinical, 3 in the clinical, and 1 in the elective, curricula-in addition to the 13 preexisting components that have been updated as appropriate. Feedback about the process from students and faculty has been overwhelmingly positive. Evaluation of curricular components and their effectiveness as an integrated sequence is ongoing. Lessons Learned: Core principles consisted of including a wide range of stakeholders to build consensus, establishing complementary student and faculty roles, using the "language of collaboration" rather than the "language of demand," presenting sexual and gender minority content in an intersectional manner whenever possible, and balancing sexual and gender minority components across the curriculum. Key practices included mapping curriculum to identify gaps; developing curriculum "pitches"; identifying early and potential later "adopters" among faculty; focusing on faculty ownership of curriculum to facilitate institutionalization; and performing ongoing tracking, assessment, and revision of curriculum.

Near-Peer Teaching Outreach Programs to Increase Minority Physician Recruitment

Problem Health disparities among racial and ethnic groups exist in the United States despite improvements in health status and access to care. These inequalities may be reduced by increasing minority physician recruitment; however, how best to recruit these physicians remains unclear.

Approach Near-peer teachers are not professionally trained, but have recently learned material that they themselves teach. Near-peer teaching in minority student outreach programs may be effective in increasing minority physician recruitment. The authors used a near-peer teaching model to promote interest in medicine, specifically ophthalmology, as a potential career path for both volunteer near-peer teachers and minority high school students participating in an educational outreach program. Twenty-one college and graduate-school near-peer teachers of various racial and ethnic backgrounds participated to teach 31 inner-city high school students. The program was evaluated using pre- and posttest surveys assessing students' knowledge about and interest in science, medicine, and ophthalmology; analysis used pairwise t-test comparisons. Qualitative responses and an end-of-training survey also assessed students' and near-peer teachers' satisfaction with the program and perceptions about medicine as a career.

Outcomes Students' knowledge about and interest in medicine and ophthalmology increased significantly after participation. Near-peer teachers agreed that teaching in the program was beneficial to their careers and made it more likely that they would enter medicine and ophthalmology.

Next Steps The authors will track the near-peer teachers' career paths and, in the next iteration, will increase the number of program days. This intervention may serve as a model for outreach for other specialties beyond ophthalmology.

Knowledge and attitudes toward transgender health

BACKGROUND

Hormonal interventions for transgender adolescents have become increasingly common; however, there is a paucity of research on medical student knowledge of, and attitudes toward, these interventions following didactic instruction. Furthermore, no studies have examined whether students can be aware of the literature on the mental health benefits of these treatments yet continue to find them unethical.

METHODS

An anonymous online survey was administered to students, from first to fourth year (n = 407), who had received one or two lectures on the treatment of youths with gender dysphoria (GD).

RESULTS

Surveys were completed by 162 respondents (40%). A majority was able to correctly answer questions regarding psychiatric co-morbidities, diagnostic criteria, hormonal interventions, long-term benefits of interventions and terminology. There was some evidence that precision in the use of terminology waned over time. Many were unclear on the role of puberty blockers and the time requirement for a diagnosis of GD. A minority (14%) reported a belief that hormonal therapy is unethical, although these same individuals recognised that these treatments have mental health benefits.

DISCUSSION

Our results have implications for future instruction, including: the need to teach pharmacological and diagnostic issues more deliberately; providing refresher training on terminology; and relying on interactive discussion or patient visits, rather than didactic lectures alone, for ethically charged medical topics. Similar levels of knowledge among students who believe that hormonal therapy is ethical and unethical may indicate that imparting didactic knowledge about therapeutic benefits alone may not be sufficient to affect attitudes regarding endocrine care for transgender youth. Hormonal interventions for transgender adolescents have become increasingly common.

Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States

CONTEXT

Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a trainee demonstrates competence in an activity, they can then be "entrusted" to practice without supervision. A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define Hospice and Palliative Medicine (HPM) EPAs.

OBJECTIVE

The objective of this study was to describe the development of a set of consensus EPAs for HPM fellowship training in the United States.

METHODS

A set of HPM EPAs was developed through an iterative consensus process involving an expert workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national registry of 3550 HPM physicians. Vetting feedback was reviewed, and survey data were statistically analyzed. Final EPA revisions followed from the multisource feedback.

RESULTS

Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors (46%). Respondents indicated that the set of 17 EPAs well represented the core activities of HPM physician practice (mean 4.72 on a five-point Likert scale) and considered all EPAs to either be "essential" or "important" with none of the EPAs ranking "neither essential, nor important."

CONCLUSIONS

A set of 17 EPAs was developed using national input of practicing physicians and program directors and an iterative expert workgroup consensus process. The workgroup anticipates that EPAs can assist fellowship directors with strengthening competency-based training curricula.

An Innovative Use of Case Conference to Teach Future Educators in Addiction Psychiatry

Objective An innovative course was developed for fellows enrolled in the Yale School of Medicine Addiction Psychiatry program to educate them in key principles of adult learning, apply these principles in a case conference presentation, and to improve skills in providing and receiving feedback. Methods An initial training module on educational skills was followed by individual mentorship to prepare a case presentation. A feedback module provided space to learn and practice skills in feedback delivery. Results The program showed positive results and improved confidence levels of the participants in presenting and providing/receiving feedback. Conclusions Implementing a course designed to improve teaching and feedback skills is feasible in a 1-year Addiction Psychiatry fellowship.

Addiction and Chronic Pain: Training Addiction Psychiatrists

OBJECTIVE

Addiction psychiatrists are increasingly asked to address chronic pain in patients with addiction. Because of historic "divisions of labor" between physicians who manage pain and addiction psychiatrists who manage addiction, limited guidance exists for preparing addiction psychiatry trainees to address this comorbidity.

METHODS

A 1-h focus group composed of five geographically well-distributed addiction psychiatry fellowship directors/faculty was conducted to explore existing curricula, identify themes, and build consensus regarding educational goals for addiction psychiatry fellows in the area of chronic pain management.

RESULTS

Discussion resulted in five broad categories of themes involving perceptions of the importance of chronic pain training for addiction psychiatrists; barriers to curriculum development (one notably being that the addiction psychiatrist's role in managing chronic pain is poorly articulated); facilitators to such development; and potential curricular content and roles of addiction psychiatrists in relation to chronic pain training.

CONCLUSION

Educators in addiction psychiatry should clarify their role in the management of chronic pain and prioritize training in this area.

Test anxiety and United States Medical Licensing Examination scores

BACKGROUND

Many medical students experience test anxiety, which may impair their performance in examinations. We examined the relationship between test anxiety and United States Medical Licensing Examination (USMLE) step-1 scores and determined the effect of a test-taking course on anxiety and USMLE scores.

METHODS

We randomly chose second-year students to take a test-taking strategies course (cases) from among volunteers. The remainder of the class served as controls. We measured test anxiety with the Westside Test Anxiety Scale (with possible scores of 1-5). The cases completed the Westside Test Anxiety scale at baseline, after completing the course (4 weeks) and again after taking the USLME step 1 (10 weeks). The controls completed the instrument at baseline and after taking the USMLE step 1 (10 weeks).

RESULTS

Ninety-three of 101 (92%) students participated in the study. The baseline test anxiety score for all students was 2.48 (SD 0.63). Test anxiety was inversely correlated with USMLE step 1 (β = -0.24, p = 0.01), adjusting for Medical College Admission Test (MCAT) scores. The test anxiety score of the participants decreased from 2.79 to 2.61 after the course (p = 0.09), and decreased further to 2.53 after the USMLE (p = 0.02), whereas the scores of the controls increased. The mean USMLE step-1 score was 234 for the cases and 243 for the controls (p = 0.03). Many medical students experience test anxiety, which may impair their performance in examinations

DISCUSSION

Test anxiety is modestly inversely correlated with USMLE step-1 scores. A test-taking strategy course modestly reduced anxiety, but did not improve USMLE scores. More robust interventions that achieve greater reductions in text anxiety may improve test scores.

Characteristics of test anxiety among medical students and congruence of strategies to address it

INTRODUCTION

Medical students may experience test anxiety associated with 'high stakes' exams, such as Step 1 of the United States Medical Licensing Examination.

METHODS

We collected qualitative responses about test anxiety at three points in time from 93 second-year medical students engaged in studying for and taking Step 1.

RESULTS

Causes of test anxiety as reported by students were related to negative self-talk during preparation for the exam. Effects of anxiety had to do with emotional well-being, cognitive functioning, and physical well-being. Strategies included socializing with others and a variety of cognitive and physical approaches. Comparison of individuals' strategies with causes and effects showed some congruence, but substantial incongruence between the types of strategies chosen and the reported causes and effects of test anxiety.

DISCUSSION

Students' adoption of a 'menu' of strategies rather than one or two carefully selected strategies suggest inefficiencies that might be addressed by interventions, such as advisor-directed conversations with students and incorporating student self-assessment and strategies for managing anxiety within courses on test-taking. Such interventions are in need of further study. An annotated list of evidence-based strategies would be helpful to students and educators. Most important, test anxiety should be viewed by medical educators as a 'real' experience, and students would benefit from educator support.

Guiding principles for the development of global health education curricula in undergraduate medical education

BACKGROUND

Global health education (GHE) at undergraduate medical institutions has expanded significantly over the last 30 years, but many questions remain regarding the best practices for the development and implementation of global health programs.

AIM

To identify key themes essential to the development of GHE programs.

METHOD

We discuss five themes relevant to GHE in the context of existing literature and practice.

RESULTS

The following themes are essential to the development of GHE programs: the definition and scope of GHE, student competencies in global health, the challenges and opportunities associated with inter-institutional relationships, principles for GHE student placements, and the evaluation of GHE programs. We place these themes in the context of current literature and practice, and provide practical guidance on how these themes might be successfully implemented by institutions seeking to develop or refine GHE programs.

CONCLUSIONS

Institutions developing or evaluating GHE programs should focus on these themes as they build their global health curricula.

Systems-based practice defined: taxonomy development and role identification for competency assessment of residents

PURPOSE

To demonstrate a methodology for coding and taxonomy development and to operationally define residents' competence in systems-based practice (SBP) in terms of observable roles, actions, and behaviors.

METHODS

The Accreditation Council for Graduate Medical Education's (ACGME's) full-text definition of SBP and the 6 discrete expectations it contains were content analyzed. Structured interviews of 88 health care professionals using a variant of focus group interviews called nominal group processes were conducted and qualitatively analyzed to identify the key attributes of SBP. Themes obtained from these 2 procedures were conceptually matched and organized to create a taxonomy of observable SPB behaviors and the SBP domain.

RESULTS

Six general resident roles emerged, under which 35 specific behavioral attributes were subsumed. From the SBP domain specified. Sample SBP items categorized by roles were derived that reflected "in-context" representations of ACGME SBP expectations.

CONCLUSION

Our comprehensive analysis created an operational representation of the SBP competency. The taxonomy development model provides a framework for constructing assessment instrument(s) that could be applied to the other ACGME competencies or complex concepts in medical education.

Perspectives on probation and mandated mental health treatment in specialized and traditional probation departments

Despite the prevalence of mentally ill probationers, and probation officers' (POs') central role in their supervision, this is the first reported study to investigate how POs implement mandates to participate in psychiatric treatment. Five focus groups were conducted in major cities with 32 POs and 20 probationers representing a mix of traditional and "specialty" probation agencies. Three key findings resulted. First, there were considerable differences between POs in specialty and traditional agencies in the nature, range, and timing of strategies applied to monitor and enforce treatment compliance. Second, the quality of PO-probationer relationships colored POs' use of these strategies and was perceived as central to probationer outcomes. Relationships characterized by a respectful, personal, approach were perceived as more effective in achieving desired outcomes than those that were more authoritarian. Third, specialty agencies strongly emphasized offender rehabilitation whereas traditional agencies focused more exclusively on community safety. These agencies differed in how well probationers with mental illness "fit" their standard operating procedure. Implications for future research and directions for probation practice are discussed.

A participant observation study using actors at 30 publicly funded HIV counseling and testing sites in Pennsylvania

OBJECTIVES

This study was designed to augment an evaluation of Pennsylvania publicly funded HIV counseling and testing sites, particularly of the staff-client interaction.

METHODS

Actors were trained as research assistants and sent to 30 randomly chosen sites to be tested and counseled for HIV disease. Instruments based on Centers for Disease Control and Prevention (CDC) guidelines were designed and used to evaluate them.

RESULTS

Data were generated that identified the range of compliance with CDC guidelines and state policy. Among the findings were that 10 of 30 sites required signed consents despite a state policy allowing anonymous testing. Only 17% of providers developed a written risk reduction plan, even though 69% of all sites surveyed by mail asserted that such plans were developed. Only 2 of 5 HIV-positive actors were offered partner notification services, even though 100% of sites visited by an interviewer claimed to offer such services.

CONCLUSIONS

The findings suggest that although evaluation methods such as mail surveys and site visits are useful for evaluating the existence of appropriate policies and protocols and gathering baseline data, they might not be sufficient for assessing actual staff-client interaction.