Imprecise Clinical Assessments and Inaccurate Grades: Family Medicine Clerkship Director Perspectives.

BACKGROUND AND OBJECTIVES: As application to residency programs becomes increasingly competitive, educational leaders face growing student concern about imprecise clinical assessments and clerkship grades. METHODS: As part of a large annual survey of family medicine clerkship directors (FMCDs), 10 questions were disseminated in May 2023 about perceived levels of imprecise assessments by faculty. We aimed to determine to what extent respondents felt their institution's evaluation system propagated inaccurate grading. RESULTS: A total of 52% of 169 FMCDs responded to the survey. Of these, 7% of respondents were completely confident that their preceptors would give two students of identical competence the same clinical evaluation rating. FMCDs estimated that an average of 38% of their preceptors inaccurately rate student performance. Most clerkships use an Honors/High Pass/Pass/Fail grading system. We found that 51% of FMCDs prefer to use a different grading paradigm than they currently use. We asked FMCDs to estimate the percentage of students that expressed concern over inaccurate preceptor ratings. Grading systems with more tiers were associated with a higher percentage of concerned students. CONCLUSIONS: Clerkship grades are widely used by residency program directors to classify and differentiate student applicants. We identified a significant concern from FMCDs that clinical evaluation ratings can vary greatly. Given the high stakes and perceived inaccuracy of clerkship grading, we recommend continued investigation into the appropriate weighing and usage of clinical evaluations. Continued exploration is recommended to develop grading paradigms centered on criterion-based assessment.

Addressing unprofessional behaviors in the clinical learning environment: lessons from a multi-year virtual, intergenerational, interdisciplinary workshop.

INTRODUCTION: Optimizing the clinical learning environment (CLE) is a medical education priority nationwide. MATERIALS AND METHODS: We developed a virtual, one-hour workshop engaging students, housestaff and faculty in small-group discussions of five case scenarios adapted from reported unprofessional behaviors in the CLE, plus didactics regarding mistreatment, microaggressions and bystander interventions. RESULTS: Over two sessions (2021-2022), we engaged 340 students and 73 faculty/housestaff facilitators. Post-session surveys showed significant improvement in participants' ability to recognize and respond to challenges in the CLE. DISCUSSION: Our innovative workshop, including scenarios derived from institutional reports of unprofessional behaviors, advanced participants' knowledge and commitment to improve the CLE.

Psychiatry Vice Chairs of Education: Expected and Actual Responsibilities, Satisfaction, and Work Barriers.

OBJECTIVES: The current study investigated the gap between actual and expected work responsibilities of psychiatry vice chairs of education (VCEs), their work satisfaction, and perceived work barriers. METHODS: Psychiatry VCEs were identified through professional memberships and school websites within the USA. In 2021, identified VCEs were emailed an anonymous survey that was based on past research on roles and responsibilities of VCEs. Through qualitative and quantitative questions, the survey assessed demographic characteristics, actual and expected work responsibilities, work satisfaction, and work barriers during time spent in the VCE role. RESULTS: Of 57 identified psychiatry VCEs, 32 (56.1%) completed the survey. Most respondents (59.4%) said their department/institution did not have a written VCE job description. There were gaps between actual and expected VCE responsibilities, especially with the performance review of education leaders (Δ - 11; actual n = 20 vs. expected n = 31). The greatest satisfaction came from mentoring trainees/faculty (respectively 4.88 ± 0.33 and 4.85 ± 0.37 on a 5-point scale) and overseeing/supporting educational programs (4.66 ± 0.48). Comments on work barriers included limited protected time (n = 11), education budget constraints (n = 6), and having multiple leadership roles (n = 5). The actual full-time equivalent in the VCE role was significantly lower than expected (p < .001). CONCLUSION: Considering the role of psychiatry VCEs remains relatively new and is evolving, adequate allocation of resources and improved job descriptions may help close the gap between expected and actual responsibilities. The current findings can assist in developing such job descriptions to attract and define the work of a VCE based on specific responsibilities and associated work satisfaction.

Climate Change as a Social Determinant of Health: An Interactive Case-Based Learning Activity.

Introduction: Despite consensus on climate change's impact on humans, medical schools have not widely adopted inclusion of environmental topics into their mandatory curriculum. This educational activity explicitly addresses climate change as one of the environmental determinants of health (EDH). Methods: We developed a required, 1-hour module for all first-year medical students. This interactive, case-based, small-group activity was incorporated into a curriculum within an advising program but could be run independently. Before and after the session, participants completed evaluations assessing knowledge gains and attitude shifts. Results: Of 183 first-year students, 155 completed both pre- and postmodule surveys. Participants' rating increased on the postmodule survey item "priority should be given to the discussion of EDH in medical education." The Wilcoxon signed rank test determined this difference in priority was statistically significant (p < .001). Reported strengths of this activity included the cases, informative content on EDH, the video, the discussion, and highlighted EDH resources. Suggested areas for improvement included more information on how to apply concepts to clinical contexts, guidance on how to engage in EDH concepts, and more discussion time. As a result of the module, students planned to engage in recycling, reduced consumption, advocacy, and changes to mode of transportation. Discussion: Climate change remains the greatest global threat to human health, and future physicians must be equipped to educate patients and policymakers on the harms of environmental hazards. This brief yet effective module offers one approach to incorporating this topic into medical school curricula.

Pharmacy students' perceptions of clinical reasoning development through a foundational thinking application framework.

BACKGROUND AND PURPOSE: Pharmacy students must learn to integrate the foundational and clinical sciences to make therapeutic decisions. There is a need for a developmental framework and scaffolding tools to bridge foundational knowledge with clinical reasoning among novice learners in pharmacy education. Our purpose is to describe the development and student perceptions of a framework designed to integrate foundational knowledge and clinical reasoning in second-year pharmacy students. EDUCATIONAL ACTIVITY AND SETTING: Using script theory as a conceptual model, a Foundational Thinking Application Framework (FTAF) was designed around a four-credit Pharmacotherapy of Nervous Systems Disorders course at the beginning of the second year of the doctor of pharmacy curriculum. The framework was implemented as two structured learning guides known as a unit plan and a pharmacologically based therapeutic evaluation. A total of 71 students in the course were asked to complete a 15-question online survey assessing perceptions towards specific components of the FTAF. FINDINGS: Of 39 survey respondents, 37 (95%) described the unit plan as a useful organizer for the course. Thirty-five (80%) students agreed or strongly agreed that the unit plan helped organize instructional material for a given topic. Students (n = 32, 82%) preferred the pharmacologically based therapeutic evaluation format, with text comments highlighting that it provided good practice for clinical experiences and helped to organize critical thinking. SUMMARY: Our study found that students had positive perceptions of FTAF's implementation within a pharmacotherapy course. Pharmacy education can benefit by adapting script-based strategies that have been successful in other health professions.

Becoming a Doctor During a Pandemic: Impact on Medical Student Social Identity Formation.

The COVID-19 pandemic required modifications to undergraduate medical education that likely affected medical students' social identity formation (SIF). SIF is shaped by experiences throughout the medical education continuum. This commentary explores factors potentially affecting medical student SIF during the COVID-19 pandemic focusing on students' perceptions of being part of the healthcare team, their role in medicine, and their engagement during the pandemic. Based on such considerations, we propose that educators should aim to design effective learning environments to support a full educational experience that encompasses acquiring medical knowledge and building strong social identities even during a pandemic.

Taking Leave During Residency: Types of Absences and Subsequent Delays and Variations in Physical Medicine and Rehabilitation Medical Board Pass Rates.

ABSTRACT: There is limited literature examining the reasons physical medicine and rehabilitation residents take an extended leave of absence during residency and the impact of leave on board examination performance. Such information could better inform leave policies, help guide residency program directors, and potentially destigmatize taking leave. Study objectives were to describe the characteristics of physical medicine and rehabilitation residents who take leave during residency, compare differences in part I (written) and part II (oral) certification examination performance, and determine the prevalence of delays in taking board examinations. Study methodology was a retrospective analysis of deidentified information from the American Board of Physical Medicine and Rehabilitation database between 2008 and 2020. Results indicated four reasons for extended leave of absence: medical, parental, academic/remediation, and unspecified personal reasons. Residents who took an extended leave of absence for medical or parental reasons had similar or better odds of passing their part I and part II examinations compared with those without leave. Residents who took leave for academic/remediation concerns or unspecified personal reasons had lower odds of passing their board examinations. Examination delays for those taking parental or personal health leaves did not affect board pass rates. Further investigation is needed to identify how to support residents on academic/remediation and unspecified leaves during training.

Influence of Psychological Safety and Organizational Support on the Impact of Humiliation on Trainee Well-Being.

OBJECTIVES: To develop physicians who can practice safely, we need better understanding of how the clinical learning environment affects trainee well-being. Two psychosocial constructs may help us understand the context: psychological safety (belief one can speak up without concerns) and perceived organizational support (degree to which members feel that their organization cares for them and values their contributions). The objective of this study is to test a moderated mediation model to determine how humiliation (X) impacts trainees' well-being (Y) while taking into account psychological safety (mediator) and organizational support (moderator). METHODS: Between May and June 2018, a single health system recruited resident physicians across 19 programs to complete an anonymous electronic survey to assess facets of the clinical learning environment, well-being, and experiences of humiliation. In a moderated mediation analysis, mediation helps explain how a predictor variable (X) impacts an outcome variable (Y) through a mediating variable, whereas moderation helps explain under what conditions such a relationship exists. RESULTS: Of 428 residents, 303 responded (71%) to the survey across 19 training programs. The effects of humiliation on well-being were mitigated by psychological safety, which varied depending on the levels of perceived organizational support. Environments rated 1 SD below the mean on perceived organization support by residents had a stronger negative impact of public humiliation on psychological safety. CONCLUSIONS: The findings suggest that humiliation is associated with well-being through the effects of psychological safety and influenced by organizational support. Further work might explore the relationship by investing resources (e.g., faculty development, mentorship) to increase psychological safety and reduce humiliation during training, especially within environments prone to be perceived as unsupportive of trainees.

Towards equitable learning environments for medical education: Bias and the intersection of social identities.

CONTEXT: Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences. METHODS: This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities. RESULTS: Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in-group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management. CONCLUSIONS: Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all.

From education to action: Development and evaluation of a student-directed service learning program.

PURPOSE: Service learning consists of service activities that respond to community-identified concerns, active learning about the population being served, and self-reflecting on the experience. The Service Learning Program (SLP) is a novel, student-led, longitudinal volunteering experience designed to address social determinants of health (SDOH) education in the undergraduate medical school curriculum. In this program, medical students complete requirements in three domains of service, education, and self-reflection over the span of one academic year. METHODS AND MATERIALS: Participating students are sent surveys prior to and after a year of participation in SLP, which are aimed to measure changes in their perceived knowledge, attitudes, and skills in multiple domains related to service learning and social determinants of health. RESULTS: Over the course of the 2019-2020 year, 110 students who participated in SLP responded to both pre- and post-surveys. These students reported significant improvements in their confidence in various knowledge and skills related to SDOH, such as identifying vulnerable populations and assessing community needs. They also were more likely to report that learning about social determinants of health was 'very important' after participating the program. CONCLUSIONS: Medical students participating in a longitudinal service learning program focused on SDOH can acquire knowledge and skills that will empower them to understand, advocate, and care for underserved populations as future physicians. This program provides a model for integrating service learning into undergraduate medical education.

Applying the Plan-Do-Study-Act cycle in medical education to refine an antibiotics therapy active learning session.

BACKGROUND: Active learning improves learner engagement and knowledge retention. The application of continuous quality improvement methodologies, such as the Plan-Do-Study-Act (PDSA) framework, may be useful for optimizing medical education, including active learning sessions. We aimed to enhance student satisfaction and achievement of learning outcomes by applying the PDSA framework to an antibiotic utilization curriculum for medical students. METHODS: Guided by the Plan-Do-Study-Act framework, between February 2017 and July 2019, we developed, implemented, and revised an active learning session for medical students, focused on appropriate utilization of antibiotics during their Internal Medicine clerkship. RESULTS: Across twelve sessions, 367 students (83.4%) completed the post-evaluation survey. Although baseline ratings were high (97% of respondents enjoyed the "active learning" format), constructive comments informed iterative improvements to the session, such as modifying session timing, handouts and organization of the gaming component. Intervention 3, the last improvement cycle, resulted in more favorable ratings for the active learning format (p = 0.015) improvement in understanding antibiotics and their clinical application (p = 0.001) compared to Baseline ratings. CONCLUSIONS: This intervention suggests that active learning, with regular incorporation of student feedback vis-à-vis a PDSA cycle, was effective in achieving high student engagement in an Internal Medicine core clerkship session on antibiotic therapy. Iterative interventions based on student feedback, such as providing an antibiotic reference table and answer choices for each case, further improved student receptivity and perceived educational value. The study findings have potential implications for medical education and suggest that the application of the PDSA cycle can optimize active learning pedagogies and outcomes.

Variations in Medical Students' Educational Preferences, Attitudes and Volunteerism during the COVID-19 Global Pandemic.

Public health crises require individuals, often volunteers, to help minimize disasters. The COVID-19 pandemic required such activation of individuals, but little is known about medical students' preferences of such engagement. We investigated potential variations in medical students' educational preferences, attitudes, and volunteerism during the COVID-19 pandemic based on socio-demographics to better prepare for future activation scenarios. A web-based, anonymous survey of U.S. medical students at a single institution was conducted in May 2020. Across four training year, 518 (68% response rate) students completed the survey. During the pandemic, 42.3% (n = 215) wanted to discontinue in-person clinical experiences, 32.3% (n = 164) wanted to continue, and 25.4% (n = 129) were neutral. There was no gender effect for engagement in volunteer activities or preference to engage in clinical activities during the pandemic. However, second-year (n = 59, 11.6%) and third-year students (n = 58, 11.4%) wanted to continue in-person clinical experiences at a greater proportion than expected, while a small proportion of fourth-year students (n = 17, 3.3%) wanted to continue, χ2(6) = 43.48, p < .001, φ = 0.29. Majority of respondents (n = 287, 55.5%) volunteered in clinical and non-clinical settings. A lower proportion of fourth-year (n = 12, 2.3%) and first-year students (n = 50, 9.7%) volunteered than expected. Likelihood to volunteer during a pandemic varied by gender, training year, and/or prior experience with disaster event depending on the type of volunteer-site setting. Our findings suggest socio-demographic factors may impact medical student engagement and volunteerism during a public health crisis. Educational leadership should be sensitive to such variations and can facilitate volunteer activities that allow student engagement during future pandemics.

Incidence of resident mistreatment in the learning environment across three institutions.

INTRODUCTION: Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment. METHODS: Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences. RESULTS: Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior. CONCLUSION: Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.

Surgery Resident Perceptions of the Clicker Evaluation System: A Novel Approach to Collecting and Utilizing Clinical Faculty Performance Data.

OBJECTIVE: Medical trainees often have a process in place to receive feedback from clinical faculty regarding overall performance. While there is guidance on effective methodologies for faculty to provide feedback for learners, there is a dearth of literature analyzing trainees' evaluation of faculty performance. We sought to identify an effective and anonymous method for surgery residents to evaluate clinical faculty. DESIGN: The Department of Orthopedic Surgery at Virginia Commonwealth University (VCU) Health implemented a novel process to gather annual clinical faculty performance data from residents for the purpose of program improvement starting in 2012. Specifically, residents used a web-based audience response system, also known as a "clicker" system, to evaluate faculty performance over the academic year. During the June 2018 evaluation session, residents also completed an anonymous, 9 question survey to assess the residents' perceptions regarding this clicker evaluation process. SETTING: VCU Health System, a tertiary care hospital in Richmond, Virginia. PARTICIPANTS: All 24 orthopaedic surgery residents at VCU Health participated in the evaluation process and completed the perception survey in 2018. RESULTS: Ninety-six percent (n = 23) of the residents agreed that they are able to accurately rate their attendings' performance, felt confident that their responses remained anonymous, and that their departmental chair values their opinion when evaluating their attendings' performance through the clicker process. Qualitative responses identified anonymity as a strength of the clicker process, while opportunities for improvement included refinement of questions. CONCLUSIONS: The clicker evaluation system is an effective and anonymous method for resident evaluation of clinical faculty performance in academic settings. Future steps include refinement of questions based on departmental goals for education, adoption of the clicker evaluation system by other specialties, as well as research into ways to optimize the clicker evaluation process. Additional research should be done to see if and how the clicker evaluation feedback translates into change in clinical faculty behavior.

Family Medicine Clerkship Directors' Handling of Student Mistreatment: Results From a CERA Survey.

BACKGROUND AND OBJECTIVES: Little is known about how family medicine clerkship directors (FMCDs) handle reports of student mistreatment. We investigated FMCDs' involvement in handling and resolving these reports. METHODS: We collected data as part of the 2019 CERA survey of FMCDs. FMCDs provided responses on how they handled student mistreatment reports and their comfort level in resolving these reports. RESULTS: Ninety-nine out of 142 FMCDs (69.7%) responded to the survey. Regarding mistreatment reports, 24.2% of FMCDs had received at least one report of student mistreatment about full-time faculty in the past 3 years, compared to 64.6% of FMCDs receiving at least one report about community preceptors (P<.001). Regarding who determined the response to the mistreatment, 13.1% of FMCDs were the highest level of leadership responsible for stopping use of a full-time faculty member for mistreatment concerns, while 42.4% of FMCDs were the highest level of leadership responsible for stopping use of a community preceptor. Regarding their comfort level in resolving mistreatment reports, 59.1% of FMCDs were either somewhat or very comfortable resolving a mistreatment report about a community preceptor, while only 48.9% reported those comfort levels for full-time faculty. FMCDs who had previously stopped using full-time faculty and/or community preceptors due to mistreatment reports were less likely to feel comfortable with resolving reports about full-time faculty compared to those who had no such experience (P=.03). CONCLUSIONS: FMCDs more frequently receive mistreatment reports about community preceptors than full-time faculty and are more likely to be the highest decision maker to stop using a community preceptor for mistreatment concerns. Further study is needed to elucidate factors that affect FMCDs' comfort in handling student mistreatment reports.

Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Professionals' Speaking-up Skills Training.

Communication failures in healthcare constitute a major root cause of adverse events and medical errors. Considerable evidence links failures to raise concerns about patient harm in a timely manner with errors in medication administration, hygiene and isolation, treatment decisions, or invasive procedures. Expressing one's concern while navigating the power hierarchy requires formal training that targets both the speaker's emotional and verbal skills and the receiver's listening skills. We conducted a scoping review to examine the scope and components of training programs that targeted healthcare professionals' speaking-up skills. Out of 9,627 screened studies, 14 studies published between 2005 and 2018 met the inclusion criteria. The majority of the existing training exclusively relied on one-time training, mostly in simulation settings, involving subjects from the same profession. In addition, most studies implicitly referred to positional power as defined by titles; few addressed other forms of power such as personal resources (e.g., expertise, information). Almost none addressed the emotional and psychological dimensions of speaking up. The existing literature provides limited evidence identifying effective training components that positively affect speaking-up behaviors and attitudes. Future opportunities include examining the role of healthcare professionals' conflict engagement style or leaders' behaviors as factors that promote speaking-up behaviors.

Physician mistreatment in the clinical learning environment.

BACKGROUND: Mistreatment has been correlated with burnout and poor well-being in medical students, but data regarding residents and faculty are limited. The objective was to investigate the prevalence of mistreatment towards surgical housestaff and faculty and characterize such experiences. METHODS: In 2018, the Department of Surgery surveyed housestaff and faculty on incidents of mistreatment. RESULTS: Clinical faculty (63%) and residents (72%) completed the mistreatment survey. Excluding public embarrassment, 48% of residents and 29% of clinical faculty experienced mistreatment. Residents experienced public embarrassment and public humiliation more frequently than faculty, however faculty were subjected to racially or ethnically offensive remarks/names more frequently than residents (p < .05). Faculty within and external to their department were most cited as instigators of mistreatment. Residents experienced mistreatment most often by faculty, co-residents, and nurses. Reporting of the behaviors was low. CONCLUSIONS: Incidents of mistreatment are frequently occurring for surgical residents and faculty.