Medical students' career decision-making stress during clinical clerkships

OBJECTIVES

Many medical students experience career decision-making stress in the final phase of training. Yet, the factors that induce or reduce career decision-making stress and how progression in their clerkships relates to these factors are unknown. This knowledge gap limits the possibilities for medical schools to develop and implement interventions targeting students' career decision-making stress. This study explores content, process, and context factors that may affect career decision-making stress.

METHODS

Using cross-sectional survey data from medical master students (n = 507), we assessed content (future work self), process (choice irreversibility, time pressure, career decision-making self-efficacy), and context (supervisory support, medical school support, study load, competition) factors and their relationships with career decision-making stress. The hypothesized relationships were tested with structural equation modelling.

RESULTS

A clearer future work self and higher career decision self-efficacy were associated with lower career decision-making stress, while experienced time pressure, competition, and study load were associated with higher career decision-making stress. Choice-irreversibility beliefs, supervisory support, and medical school support were unrelated to career decision-making stress. As students' clerkships progressed, they gained a clearer future work self, but also experienced more time pressure.

DISCUSSION

Clinical clerkships help students to form a clearer future work self, which can diminish career decision-making stress. Yet, students also experience more time pressure as the period of clerkships lengthens, which can increase career decision-making stress. A school climate of high competition and study load seems to foster career decision-making stress, while school support hardly seems effective in diminishing this stress.

How medical students co-regulate their learning in clinical clerkships: a social network study

BACKGROUND

Self-regulated learning is a key competence to engage in lifelong learning. Research increasingly acknowledges that medical students in clerkships need others to regulate their learning. The concept of "co-regulated learning" captures this act of regulating one's learning by interacting with others. To effectively cultivate such skills in students, we need to increase our understanding of co-regulated learning. This study aimed to identify the purposes for which students in different phases of clinical training engage others in their networks to regulate their learning.

METHODS

In this social network study, we administered a questionnaire to 403 medical students during clinical clerkships (65.5% response rate). The questionnaire probed into the composition of students' co-regulatory networks and the purpose for which they engaged others in specified self-regulated learning activities. We calculated the proportion of students that engaged others in their networks for each regulatory activity. Additionally, we conducted ANOVAs to examine whether first-, second-, and third-year students differed in how they used their networks to support self-regulation.

RESULTS

Students used others within their co-regulatory networks to support a range of self-regulated learning activities. Whom students engaged, and the purpose of engagement, seemed to shift as students progressed through clinical training. Over time, the proportion of students engaging workplace supervisors to discuss learning goals, learning strategies, self-reflections and self-evaluations increased, whereas the proportion of students engaging peers to discuss learning strategies and how to work on learning goals in the workplace decreased. Of all purposes for which students engaged others measured, discussing self-reflections and self-evaluations were consistently among the ones most frequently mentioned.

CONCLUSIONS

Results reinforce the notion that medical students' regulation of learning is grounded in social interactions within co-regulatory networks students construct during clerkships. Findings elucidate the extent to which students enact self-regulatory learning within their co-regulatory networks and how their co-regulatory learning behaviors develop over time. Explicating the relevance of interactions within co-regulatory networks might help students and supervisors to purposefully engage in meaningful co-regulatory interactions. Additionally, co-regulatory interactions may assist students in regulating their learning in clinical workplaces as well as in honing their self-regulated learning skills.

Reading and Study Habits of Medical Students on Clerkships and Performance Outcomes: a Multi-institutional Study

PURPOSE

To describe medical students' reading habits and resources used during clinical clerkships, and to assess whether these are associated with performance outcomes.

METHOD

Authors administered a cross-sectional survey to medical students at 3 schools midway through the clerkship year. Closed and open-ended questions focused on resources used to read and learn during the most recent clerkship, time spent and purpose for using these resources, influencers on study habits, and barriers. A multiple regression model was used to predict performance outcomes.

RESULTS

Overall response rate was 53% (158/293). Students spent most of their time studying for clerkship exams and rated question banks and board review books as most useful for exam preparation. Sixty-seven percent used textbooks (including pocket-size). For patient care, online databases and pocket-sized textbooks were rated most useful. The main barrier to reading was time. Eighty percent of students ranked classmates/senior students as most influential regarding recommended resources. Hours spent reading for exams was the only significant predictor of USMLE Step 2 scores related to study habits. The predominant advice offered to future students was to read.

CONCLUSIONS

These findings can help inform students and educational leadership about resources students use, how they use them, and links to performance outcomes, in an effort to guide them on maximizing learning on busy clerkships. With peers being most influential, it is important not only to provide time to help students build strong reading and study habits early, but also to guide them towards reliable resources, so they will recommend useful information to others.

Embedding Ethics Education in Clinical Clerkships by Identifying Clinical Ethics Competencies: The Vanderbilt Experience

The clinical clerkships in medical school are the first formal opportunity for trainees to apply bioethics concepts to clinical encounters. These clerkships are also typically trainees' first sustained exposure to the "reality" of working in clinical teams and the full force of the challenges and ethical tensions of clinical care. We have developed a specialized, embedded ethics curriculum for Vanderbilt University medical students during their second (clerkship) year to address the unique experience of trainees' first exposure to clinical care. Our embedded curriculum is centered around core "ethics competencies" specific to the clerkship: for Medicine, advanced planning and end-of-life discussions; for Surgery, informed consent; for Pediatrics, the patient-family-provider triad; for Obstetrics and Gynecology, women's autonomy, unborn child's interests, and partner's rights; and for Neurology/Psychiatry, decision-making capacity. In this paper, we present the rationale for these competencies, how we integrated them into the clerkships, and how we assessed these competencies. We also review the additional ethical issues that have been identified by rotating students in each clerkship and discuss our strategies for continued evolution of our ethics curriculum.

From Knowing to Doing: Integrating Systems-Ready Physician Competencies in the Clerkship Setting

There are increasing calls to graduate physicians with a strong understanding of health systems science (HSS). Many schools have incorporated didactics on health systems science content such as quality improvement, patient safety, or interprofessional education. Creating a systems-ready physician requires more than teaching content in classroom settings. Using Miller's pyramid of assessment of clinical performance, we have developed strategies to move our learners from the cognitive-based "knows" level to the behavior-based "does" level of understanding of the HSS competencies. Our medical students begin learning HSS in classroom settings. Next, the students apply this knowledge during their core clerkships. This gives them an opportunity to get feedback increasingly from high-fidelity clinical settings. We embedded assessment strategies and tools in the clerkship year to facilitate the demonstration, observation, and assessment of HSS competencies in the setting of our core clerkships. We also have students self-assess their competence in our graduation competencies at the end of each year. Student self-assessment from the beginning of the clerkship year to the end showed significant increases in the HSS competencies. Our clerkship student assessment data from our first cohort suggest that faculty had difficulty observing and assessing some of the competencies unique to health systems science. The clerkships have developed multiple projects and assignments to allow students to demonstrate HSS competencies. Faculty and resident training to prompt, observe, and assess these competencies is ongoing to close the assessment gap. In the area of professionalism, student self-assessment and faculty clinical assessment correlate strongly.

Evaluation of the effect of items' format and type on psychometric properties of sixth year pharmacy students clinical clerkship assessment items

BACKGROUND

Examinations are the traditional assessment tools. In addition to measurement of learning, exams are used to guide the improvement of academic programs. The current study attempted to evaluate the quality of assessment items of sixth year clinical clerkships examinations as a function of assessment items format and type/structure and to assess the effect of the number of response choices on the characteristics of MCQs as assessment items.

METHODS

A total of 173 assessment items used in the examinations of sixth year clinical clerkships of a PharmD program were included. Items were classified as case based or noncase based and as MCQs or open-ended. The psychometric characteristics of the items were studied as a function of the Bloom's levels addressed, item format, and number of choices in MCQs.

RESULTS

Items addressing analysis skills were more difficult. No differences were found between case based and noncase based items in terms of their difficulty, with a slightly better discrimination in the latter. Open-ended items were easier, yet more discriminative. MCQs with higher number of options were easier. Open-ended questions were significantly more discriminative in comparison to MCQs as case based items while they were more discriminative as noncase based items.

CONCLUSION

Item formats, structure, and number of options in MCQs significantly affected the psychometric properties of the studied items. Noncase based items and open-ended items were easier and more discriminative than case based items and MCQs, respectively. Examination items should be prepared considering the above characteristics to improve their psychometric properties and maximize their usefulness.

Personality Traits Are Associated with Academic Achievement in Medical School: A Nationally Representative Study

OBJECTIVE

This nationally representative study sought to identify personality traits that are associated with academic achievement in medical school.

METHODS

Third-year medical students, who completed an initial questionnaire in January 2011, were mailed a second questionnaire several months later during their fourth year. Controlling for sociodemographic characteristics and burnout, the authors used multivariate logistic regressions to determine whether Big Five personality traits were associated with receiving honors/highest grade in clinical clerkships, failing a course or rotation, and being selected for the Alpha Omega Alpha or Gold Humanism Honor Society.

RESULTS

The adjusted response rates for the two surveys were 61 (n = 564/919) and 84% (n = 474/564). The personality trait conscientiousness predicted obtaining honors/highest grade in all clinical clerkships. In contrast, students high in neuroticism were less likely to do well in most specialties. Students with higher conscientiousness were more likely to be inducted into the Alpha Omega Alpha Honor Society, while students high in openness or agreeableness traits were more likely to be inducted into the Gold Humanism Honor Society. Burnout was not associated with any clinical performance measures.

CONCLUSIONS

This study suggests the importance of personality traits, particularly conscientiousness, in predicting success during the clinical years of medical school. Medical educators should consider a nuanced examination of personality traits and other non-cognitive factors, particularly for psychiatry.

A cross-sectional examination of psychological distress, positive mental health and their predictors in medical students in their clinical clerkships

BACKGROUND

Medical students can experience the transition from theory to clinical clerkships as stressful. Scientific literature on the mental health of clinical clerkship students is scarce and mental health is usually defined as absence of psychological distress without assessing psychological, emotional and social wellbeing, together called 'positive mental health'. This cross-sectional study examines the prevalence of psychological distress and positive mental health and explores possible predictors in a Dutch sample of clinical clerkship students.

METHODS

Fourth-year medical students in their first year of clinical clerkships were invited to complete an online questionnaire assessing demographics, psychological distress (Brief Symptom Inventory), positive mental health (Mental Health Continuum- SF), dysfunctional cognitions (Irrational Beliefs Inventory) and dispositional mindfulness skills (Five Facet Mindfulness Questionnaire). Multiple linear regression analysis was used to explore relationships between psychological distress, positive mental health (dependent variables) and demographics, dysfunctional cognitions and dispositional mindfulness skills (predictors).

RESULTS

Of 454 eligible students, 406 (89%) completed the assessment of whom 21% scored in the clinical range of psychological distress and 41% reported a flourishing mental health. These proportions partially overlap each other. Female students reported a significantly higher mean level of psychological distress than males. In the regression analysis the strongest predictors of psychological distress were 'acting with awareness' (negative) and 'worrying' (positive). Strongest predictors of positive mental health were 'problem avoidance' (negative) and 'emotional irresponsibility' (negative).

CONCLUSIONS

The prevalence of psychopathology in our sample of Dutch clinical clerkship students is slightly higher than in the general population. Our results support conclusions of previous research that psychological distress and positive mental health are not two ends of one continuum but partially overlap. Although no conclusion on causality can be drawn, this study supports the idea that self-awareness and active, nonavoidant coping strategies are related to lower distress and higher positive mental health.