Revealing the Hidden Clerkship Curriculum: A Qualitative Analysis.

BACKGROUND AND OBJECTIVES: Family medicine (FM) clerkships have learning objectives to define what students should learn by the end of their clerkship, but how do we know what larger lessons students are taking away? This study aimed to explore the FM clerkship explicit and hidden curriculum. METHODS: Students were asked to list their top five take-home points at the end of their FM clerkship at two institutions. A total of 668 written reflections were qualitatively analyzed. RESULTS: Thirteen code categories emerged: scope of practice, health care systems, role of FM in the system, traits of a family doctor, values of FM, cultural competency and social justice, challenges of FM care, evidence-based medicine, clinical skills for a student, personal impact, life skills and tips, patient centeredness, and clinical pearls. Prominent subcategories included prevention, team-based care, doctor-patient relationship, and continuity of care. CONCLUSIONS: When compared to the FM clerkship learning objectives at both institutions, four code categories emerged that were not part of the explicit objectives: traits of a family doctor, challenges in FM care, personal impact, and life skills and tips. Conversely, some nuances of the learning objective of FM in the health care system regarding decreasing cost and improving health outcomes and equity were not represented in the coded categories of student responses. These findings could potentially help FM clerkships nationally define ways to improve messaging around challenges in FM care and help the 25 x 2030 initiative to produce more family physicians in the United States.

Identifying Student Mistreatment Through Peer-Facilitated Learning Environment Sessions.

PROBLEM: Data from the Association of American Medical Colleges (AAMC) Medical School Graduation Questionnaire (GQ) show persistent high rates of medical student mistreatment, and multiple barriers to student reporting of mistreatment exist. The authors examined whether learning environment sessions (LESs) allow students opportunities to identify and describe patterns of mistreatment missed by other avenues of reporting. APPROACH: Peer-facilitated LESs were instituted in 2018-2019 at Boston University School of Medicine. The LESs were scheduled once during every third-year core clerkship block. Third- and fourth-year students trained as peer-facilitators led discussions of topics relevant to the student clinical experience using a standardized facilitator guide. Minutes, including details of reported events, were completed during the session and visible to all students participating. These minutes were sent to clerkship leadership and the medical education office for action once student grades were submitted. OUTCOMES: Summative content analysis was conducted on 44 LES minutes from sessions held in January-November 2019. Reported incidents were categorized into broad categories of negative treatment (NT), negative learning environment (NLE), and positive learning environment (PLE). Sixty-three instances of NT were identified. Of these, 37 fit within the scope of the AAMC GQ mistreatment categories. The remaining 26 instances of NT were classified into 7 novel categories of medical student mistreatment. Instances of NLE were most discussed by students and categorized into 5 subthemes. Examples of PLE were categorized into 4 subthemes, which encompassed 11 descriptors of core qualities of an ideal preceptor or educational environment. NEXT STEPS: LESs have aided in identifying and describing new patterns of mistreatment. They fulfill a unique role by allowing students to identify, analyze, and report mistreatment in a facilitated and protected space. Formal evaluations of institutional improvement in the learning environment, reduction in medical student mistreatment, and subsequent improvement in AAMC GQ data are needed.

Training Medical Students as Peer-Facilitators to Identify Medical Student Mistreatment in the Clerkship Year.

Introduction: Data from the Association of American Medical Colleges' Medical School Graduation Questionnaire show persistent trends of medical student mistreatment nationwide. To reduce the barriers and increase actionable reporting of mistreatment, we integrated peer-facilitated learning environment sessions led by a group of trained third- and fourth-year medical students in all core clinical clerkships. Methods: During the 2018-2019 academic year, third-year medical students were recruited, oriented, and trained to act as facilitators of sessions on mistreatment. The sessions occurred once every clerkship block, using a standardized session introduction and guide. After a 6-month pilot, new medical students were recruited and worked as scribe/facilitator pairs, receiving an additional 1.5-hour training midyear, which was evaluated with a postworkshop survey. Results: Thirty-eight students implemented 43 peer-facilitated sessions and completed deidentified minutes of each session, which were shared with clerkship directors and the Medical Education Office for review. Survey data from midyear facilitator training indicated that facilitators highly agreed peer-led sessions were an important avenue for students to process experiences of mistreatment (3.9 out of 4), understood barriers to reporting (3.8 out of 4) and definitions of mistreatment (3.6 out of 4), and felt confident to facilitate these sessions (3.6 out of 4). Discussion: Peer-facilitated sessions offer a method to learn more about student experiences with mistreatment in real time and create a new avenue for communication between faculty and students. Assembling a stable core team of third- and fourth-year students trained in facilitation skills ensures the sustainability and relevance of the program.

Finding Information Framework: A Tool to Teach Life-Long Learning Skills.

INTRODUCTION: In this age of rapid information expansion, medical education can no longer be taught solely by information acquisition, but rather requires information management and information mastery at both the point of learning as well as at the clinical point of care. We must teach our trainees how to ask, categorize, and answer their own questions-skills required to be a life-long learner. We developed the Finding Information Framework (FIF), a conceptual algorithm as well as web-based tool and app, to guide medical students in asking and categorizing their questions and to link them directly to the most appropriate information resource for their questions. Here we assess the functionality of the FIF following its implementation in the first-year medical school curriculum problem-based learning (PBL) course. METHODS: First-year medical students (n=126) utilized the FIF in their longitudinal problem-based learning course discussion groups and completed an anonymous survey. RESULTS: Qualitative and quantative data suggest that the FIF was easy to use (86.5%), supported the course curriculum (80%), and helped students find relevant information to answer their questions (77%) from trusted reliable resources (70%). Qualitative comments also suggest that the FIF is initially a helpful tool during the PBL course but becomes less useful over time as students become more familiar with resources. CONCLUSION: The FIF assists students in identifying trusted resources and in efficiently and effectively finding answers to questions at the point of learning. These data suggest that students are internalizing the tool's conceptual algorithm over time, reinforcing the teaching of information management and information mastery.

The One Minute Learner: Evaluation of a New Tool to Promote Discussion of Medical Student Goals and Expectations in Clinical Learning Environments.

BACKGROUND AND OBJECTIVES: The transition from pre-clerkship to clerkship curriculum in medical school presents many challenges to students. Student roles and supervising physicians' expectations vary widely. Efforts to ease this transition have included third-year orientations, skills sessions, field- specific training, and peer-to-peer communication/support. We developed a new tool, called The One Minute Learner (OML), to promote and structure discussion of student goals and expectations and empower student ownership of learning. The OML can be used quickly and easily by students and faculty to facilitate integration of medical students into the clinical setting. This paper describes the OML and reports evaluation of its effectiveness through student evaluations. METHODS: We compared student responses to two end-of-clerkship questions for the academic year before the OML was implemented to the first year of implementation. Students rated their orientation to their roles and responsibility and rated the communication of what was expected of them. RESULTS: The percentage of students rating these highly increased dramatically: for "I was oriented to my responsibilities and role," the percentage rating it highly (4--5 on a 5-point Likert scale) increased from 47% to 82%. For "Expectations of my role were communicated to me clearly" the percentage rating it highly increased from 66% to 89%. CONCLUSIONS: The OML is a new tool that can promote and structure a proactive discussion between student and teacher about goals and expectations, leading to better integration of students into the variety of clinical setting in which they rotate.

Assessing and Documenting the Cognitive Performance of Family Medicine Residents Practicing Outpatient Medicine.

BACKGROUND: Development of cognitive skills for competent medical practice is a goal of residency education. Cognitive skills must be developed for many different clinical situations. INNOVATION: We developed the Resident Cognitive Skills Documentation (CogDoc) as a method for capturing faculty members' real-time assessment of residents' cognitive performance while they precepted them in a family medicine office. The tool captures 3 dimensions of cognitive skills: medical knowledge, understanding, and its application. This article describes CogDoc development, our experience with its use, and its reliability and feasibility. METHODS: After development and pilot-testing, we introduced the CogDoc at a single training site, collecting all completed forms for 14 months to determine completion rate, competence development over time, consistency among preceptors, and resident use of the data. RESULTS: Thirty-eight faculty members completed 5021 CogDoc forms, documenting 29% of all patient visits by 33 residents. Competency was documented in all entrustable professional activities. Competence was statistically different among residents of different years of training for all 3 dimensions and progressively increased within all residency classes over time. Reliability scores were high: 0.9204 for the medical knowledge domain, 0.9405 for understanding, and 0.9414 for application. Almost every resident reported accessing the individual forms or summaries documenting their performance. CONCLUSIONS: The CogDoc approach allows for ongoing assessment and documentation of resident competence, and, when compiled over time, depicts a comprehensive assessment of residents' cognitive development and ability to make decisions in ambulatory medicine. This approach meets criteria for an acceptable tool for assessing cognitive skills.

Entrustable professional activities in family medicine.

BACKGROUND: The Accreditation Council for Graduate Medical Education Outcome Project intended to move residency education toward assessing and documenting resident competence in 6 dimensions of performance important to the practice of medicine. Although the project defined a set of general attributes of a good physician, it did not define the actual activities that a competent physician performs in practice in the given specialty. These descriptions have been called entrustable professional activities (EPAs). OBJECTIVE: We sought to develop a list of EPAs for ambulatory practice in family medicine to guide curriculum development and resident assessment. METHODS: We developed an initial list of EPAs over the course of 3 years, and we refined it further by obtaining the opinion of experts using a Delphi Process. The experts participating in this study were recruited from 2 groups of family medicine leaders: organizers and participants in the Preparing the Personal Physician for Practice initiative, and members of the Society of Teachers of Family Medicine Task Force on Competency Assessment. The experts participated in 2 rounds of anonymous, Internet-based surveys. RESULTS: A total of 22 experts participated, and 21 experts participated in both rounds of the Delphi Process. The Delphi Process reduced the number of competency areas from 91 to 76 areas, with 3 additional competency areas added in round 1. CONCLUSIONS: This list of EPAs developed through our Delphi process can be used as a starting point for family medicine residency programs interested in moving toward a competency-based approach to resident education and assessment.