Non-physician and physician preceptors in Landscapes of Practice: a mixed-methods study exploring learning for 1st-year medical students in clinical experiences.

Medical education has traditionally relied on physician educators. With expanding Health Systems Science competencies, non-physician healthcare providers are required. To investigate preceptor-role types, communication frequency, and importance of preceptors in value-added patient navigator roles (PN) and clinical preceptorships (CP). Using a mixed-methods approach, medical students participating in PN and CP during the first year of medical school (n=191) identified individuals with whom they communicated and communication frequency (1=never, 7=frequently), and importance of preceptors to work/education (1=not important, 7=extremely important; open-ended responses). Quantitative data were analyzed via repeated measures using a mixed-effects model and McNemar's test; effect size was calculated via Cohen's d or Cohen's h; qualitative data was analyzed using thematic analysis. Comparing ratings for non-physicians to physician healthcare professionals in PN, communication frequency (5.54 vs 3.65; p<0.001, d=1.18), importance to work (5.77 vs 4.28, p<0.001, d=0.89) and education (5.02 vs 4.12, p<0.001; d=0.49) were higher for non-physician educators. Comparing ratings for non-physicians to physician healthcare professionals in CP, communication frequency (4.93 vs. 6.48, p<0.001, d=1.33), importance to work (5.12 vs 6.61 vs, p<0.001, d=1.29) and education (4.32 vs 6.55, p<0.001, d=1.89) were higher for physician educators. Qualitative analysis indicated that non-physician healthcare providers in PN focused on Health Systems Science concepts, including social determinants of health and healthcare delivery. In PN, students observed collaboration from the perspective of multiple providers. In CP, healthcare providers, mainly physicians, focused on physician-centric clinical skills and interprofessional collaboration from the physician's perspective. Educational benefits of non-physician healthcare professionals related to Health Systems Science in work-based clinical settings - or Landscapes of Practice - can help students understand systems-based concepts such as social determinants of health, healthcare delivery systems, and interprofessional collaboration. Differences in the educational value of non-physician healthcare educators perceived by students should be further explored.

Implementation and Evaluation of an Interprofessional Health Systems Science Professional Development Program.

PROBLEM: Few interprofessional development programs focused on learning knowledge and skills in health systems science (HSS) have been described. The authors implemented a professional development program (the HSS Academy) for interprofessional clinicians and trainees. The authors describe the HSS Academy, report preliminary outcomes, and describe strategies for use in other programs. APPROACH: The HSS Academy (an 8-month active learning classroom and project-based curriculum) was implemented at Penn State College of Medicine in 2015. To create an interprofessional environment, participants were selected from various professions and phases of training. The curriculum was anchored in HSS competencies (e.g., high-value care, quality improvement, social determinants of health, health system strategy and delivery) and included 2 distinct threads focused on systems thinking competencies and academic skill development. It featured course speakers and faculty from diverse roles and disciplines both inside and outside the health system, application of HSS competencies in local system contexts, and networking with interprofessional colleagues. OUTCOMES: From 2015 to 2021, 121 of 128 participants, including physicians, medical students, and nurses, completed the HSS Academy (95% completion rate). Over 90 individuals, including faculty and system leaders, contributed to the HSS Academy as educators. Comparisons of pre-post evaluations demonstrated statistically significant self-perceived improvements in HSS knowledge and skills, systems thinking, and HSS teaching knowledge and skills. Projects (n = 110) most commonly focused on health care delivery, quality improvement, or patient safety. Teaching strategies to meet each objective, several barriers encountered, and strategies to address those barriers are described. NEXT STEPS: Next steps will be to address financial support for creating and sustaining the HSS Academy, ensure a mutually shared understanding of the HSS Academy's goals among all stakeholders, facilitate meaningful change from scholars' work, and provide networking and opportunities for scholars to continue work in HSS after completion of the HSS Academy.

Accelerated 3-Year MD Pathway Programs: Graduates' Perspectives on Education Quality, the Learning Environment, Residency Readiness, Debt, Burnout, and Career Plans.

PURPOSE: To compare perception of accelerated and traditional medical students, with respect to satisfaction with education quality, and the learning environment, residency readiness, burnout, debt, and career plans. METHOD: Customized 2017 and 2018 Medical School Graduation Questionnaires (GQs) were analyzed using independent samples t tests for means and chi-square tests for percentages, comparing responses of accelerated MD program graduates (accelerated pathway [AP] students) from 9 schools with those of non-AP graduates from the same 9 schools and non-AP graduates from all surveyed schools. RESULTS: GQ completion rates for the 90 AP students, 2,573 non-AP students from AP schools, and 38,116 non-AP students from all schools in 2017 and 2018 were 74.4%, 82.3%, and 83.3%, respectively. AP students were as satisfied with the quality of their education and felt as prepared for residency as non-AP students. AP students reported a more positive learning climate than non-AP students from AP schools and from all schools as measured by the student-faculty interaction (15.9 vs 14.4 and 14.3, respectively; P < .001 for both pairwise comparisons) and emotional climate (10.7 vs 9.6 and 9.6, respectively; P = .004 and .003, respectively) scales. AP students had less debt than non-AP students (P < .001), and more planned to care for underserved populations and practice family medicine than non-AP students from AP schools (55.7% vs 33.9% and 37.7% vs 9.4%; P = .002 and < .001, respectively). Family expectations were a more common influence on career plans for AP students than for non-AP students from AP schools and from all schools (26.2% vs 11.3% and 11.7%, respectively; P < .001 for both pairwise comparisons). CONCLUSIONS: These findings support accelerated programs as a potentially important intervention to address workforce shortages and rising student debt without negative impacts on student perception of burnout, education quality, or residency preparedness.

Unpacking Medical Students' Mixed Engagement in Health Systems Science Education.

Phenomenon: Medical education is better aligning with the needs of health systems. Health systems science competencies, such as high-value care, population health, and systems thinking, are increasingly being integrated into curricula, but not without challenges. One challenge is mixed receptivity by students, the underlying reasons of which have not been extensively explored. In this qualitative study, we explored the research question: "How do students perceive health systems science curricula across all four years, and how do such perceptions inform the reasons for mixed quality ratings?" Approach: Following large-scale health systems science curricular changes in their medical school, we used students' open-ended comments obtained from course evaluations related to 1st-, 2nd-, and 4th-year courses and performed a qualitative thematic analysis to explore students' perceptions. We identified themes, synthesized findings into a conceptual figure, and agreed upon results and quotations. Findings: Five themes were identified: (1) perceived importance and relevance of health systems science education, (2) tension between traditional and evolving health systems science-related professional identity, (3) dissatisfaction with redundancy of topics, (4) competition with basic and clinical science curricula, and, (5) preference for discrete, usable, testable facts over complexity and uncertainty. The relationship between themes is described along a continuum of competing agendas between students' traditional mindset (which focuses on basic/clinical science) and an emerging medical education approach (which focuses on basic, clinical, and health systems science). Insights: Health systems science education can be viewed by learners as peripheral to their future practice and not aligned with a professional identity that places emphasis on basic and clinical science topics. For some students, this traditional identity limits engagement in health systems science curricula. If health systems science is to achieve its full potential in medical education, further work is required to explore the adoption of new perspectives by students and create activities to accelerate the process.

Transformation and Closure for Anatomical Donor Families that Meet Medical Students.

The University of Oklahoma College of Medicine has conducted an annual Anatomical Donor Luncheon where families of the anatomical donors met anatomy dissection groups of medical students. The luncheon presented an opportunity for donor family members to share the life story of their loved one with the medical students prior to the start of the anatomy course. This study was designed to understand the impact of the Anatomical Donor Luncheon on families of the donors. Seven families in two different focus groups were included to explore the reactions and attitudes of the donor families to meeting the medical students. Conversations were digitally recorded and transcribed. Qualitative analysis of textual data were coded by three investigators using the Constant Comparative Method. To provide evidence of validity, a form of member checking was utilized. For further triangulation, an analyst not involved in conducting the focus groups or analyzing the data, re-coded all data. This analyst used categories and themes identified by the original analysts, ensuring validity of the themes and any negative cases (data not supporting or contradictory of the established categories and themes). One meta-theme and three sub-themes were identified. The meta-theme was Donor Family Participants Experience Transformation and Closure, and sub-themes were Motivators for Participation, Optimal Venue Factors, and Optimal Medical Student-Anatomical Donor Family Interactions. Study findings indicated the Anatomical Donor Luncheon facilitated closure on the death of their loved one, and transformed their apprehension about the luncheon and body donation into an attitude of gratitude and appreciation.

Does Pre-clerkship Medical Humanities Curriculum Support Professional Identity Formation? Early Insights from a Qualitative Study.

There is a lack of consensus about the outcomes of medical humanities training. In this qualitative study, the authors analyzed pre-clerkship small group discussions to assess the nature of learning in medical humanities. Twenty-two medical students (12 females and 10 males) in three humanities small groups consented to participate. The authors used inductive thematic analysis to qualitatively analyze the text from 13 weeks of curriculum. Findings indicate that students reflect about negotiating the clinician-patient relationship within the stressful environment characteristic of today's healthcare systems, that they worry about sacrificing their personal values in pursuit of honoring professional expectations, and that they encounter and commonly confront ambiguity. These themes were used to develop a descriptive framework of humanities small groups as a structure and safe space for the early development of professional identity.

Educating patient-centered, systems-aware physicians: a qualitative analysis of medical student perceptions of value-added clinical systems learning roles.

BACKGROUND: Medical schools have a critical need to develop roles for students that are "value-added," defined as "…experiential roles that can positively impact health outcomes while also enhancing student knowledge, attitudes, and skills in Clinical or Health Systems Science." Following implementation of value-added clinical systems learning roles for all first-year students, authors investigated student perceptions of the educational value from these patient-centered experiences. METHODS: Between 2014 and 16, authors collected logs from students following their working with patients; authors also performed six, 1:1 student interviews, which were audio recorded and transcribed verbatim. Authors used thematic analysis to explore students' perceptions of the experience and educational benefits from these roles. Authors identified themes, and agreed upon results and quotations. RESULTS: A total of 792 logs from 363 patients and six interviews were completed and analyzed. Students reported six educational benefits of performing value-added clinical systems learning roles in the health system, including enhanced understanding of and appreciation for a patient's perspective on health care and his/her health, barriers and social determinants of health, health care systems and delivery, interprofessional collaboration and teamwork, clinical medicine, and approach to communicating with patients. CONCLUSIONS: Students' reported educational benefits from value-added clinical systems learning roles span several learning areas that align with clinical and Health Systems Science, i.e. the needs of future physicians. These roles have the potential to shift learning from the physician-centric identity to one more fully aligned with patient-centered, team-based providers, while also potentially improving health today.

A practical guide for implementing and maintaining value-added clinical systems learning roles for medical students using a diffusion of innovations framework.

After emphasizing biomedical and clinical sciences for over a century, US medical schools are expanding experiential roles that allow students to learn about health care delivery while also adding value to patient care. After developing a program where all 1st-year medical students are integrated into interprofessional care teams to contribute to patient care, authors use a diffusion of innovations framework to explore and identify barriers, facilitators, and best practices for implementing value-added clinical systems learning roles. In 2016, authors conducted 32 clinical-site observations, 29 1:1 interviews with mentors, and four student focus-group interviews. Data were transcribed verbatim, and a thematic analysis was used to identify themes. Authors discussed drafts of the categorization scheme, and agreed upon results and quotations. Of 36 sites implementing the program, 17 (47%) remained, 8 (22%) significantly modified, and 11 (31%) withdrew from the program. Identified strategies for implementing value-added roles included: student education, patient characteristics, patient selection methods, activities performed, and resources. Six themes influencing program implementation and maintenance included: (1) educational benefit, (2) value added to patient care from student work, (3) mentor time and site capacity, (4) student engagement, (5) working relationship between school, site, and students, and, (6) students' continuity at the site. Health systems science is an emerging focus for medical schools, and educators are challenged to design practice-based roles that enhance education and add value to patient care. Health professions' schools implementing value-added roles will need to invest resources and strategize about best-practice strategies to guide efforts.

High-Stakes Collaborative Testing: Why Not?

Phenomenon: Studies of high-stakes collaborative testing remain sparse, especially in medical education. We explored high-stakes collaborative testing in medical education, looking specifically at the experiences of students in established and newly formed teams. APPROACH: Third-year psychiatry students at 5 medical schools across 6 sites participated, with 4 participating as established team sites and 2 as comparison team sites. For the collaborative test, we used the National Board of Medical Examiners Psychiatry subject test, administering it via a 2-stage process. Students at all sites were randomly selected to participate in a focus group, with 8-10 students per site (N = 49). We also examined quantitative data for additional triangulation. FINDINGS: Students described a range of heightened emotions around the collaborative test yet perceived it as valuable regardless if they were in established or newly formed teams. Students described learning about the subject matter, themselves, others, and interpersonal dynamics during collaborative testing. Triangulation of these results via quantitative data supported these themes. Insights: Despite student concerns, high-stakes collaborative tests may be both valuable and feasible. The data suggest that high-stakes tests (tests of learning or summative evaluation) could also become tests for learning or formative evaluation. The paucity of research into this methodology in medical education suggests more research is needed.

Aligning Education With Health Care Transformation: Identifying a Shared Mental Model of "New" Faculty Competencies for Academic Faculty.

PURPOSE: To develop a potential competency framework for faculty development programs aligned with the needs of faculty in academic health centers (AHCs). METHOD: In 2014 and 2015, the authors interviewed 23 health system leaders and analyzed transcripts using constant comparative analysis and thematic analysis. They coded competencies and curricular concepts into subcategories. Lead investigators reviewed drafts of the categorization themes and subthemes related to gaps in faculty knowledge and skills, collapsed and combined competency domains, and resolved disagreements via discussion. RESULTS: Through analysis, the authors identified four themes. The first was core functional competencies and curricular domains for conceptual learning, including patient-centered care, health care processes, clinical informatics, population and public health, policy and payment, value-based care, and health system improvement. The second was the need for foundational competency domains, including systems thinking, change agency/management, teaming, and leadership. The third theme was paradigm shifts in how academic faculty should approach health care, categorized into four areas: delivery, transformation, provider characteristics and skills, and education. The fourth theme was the need for faculty to be aware of challenges in the culture of AHCs as an influential context for change. CONCLUSIONS: This broad competency framework for faculty development programs expands existing curricula by including a comprehensive scope of health systems science content and skills. AHC leaders can use these results to better align faculty education with the real-time needs of their health systems. Future work should focus on optimal prioritization and methods for teaching.

A Constructive Reframing of Student Roles and Systems Learning in Medical Education Using a Communities of Practice Lens.

Health systems are in the midst of a transformation that is being driven by a variety of forces. This has important implications for medical educators because clinical practice environments play a key role in learning and professional development, and evolving health systems are beginning to demand that providers have "systems-ready" knowledge, attitudes, and skills. Such implications provide a clear mandate for medical schools to modify their goals and prepare physicians to practice flexibly within teams and effectively contribute to the improvement of health care delivery. In this context, the concepts of value-added medical education, authentic student roles, and health systems science are emerging as increasingly important. In this Article, the authors use a lens informed by communities of practice theory to explore these three concepts, examining the implications that the communities of practice theory has in the constructive reframing of educational practices-particularly common student roles and experiences-and charting future directions for medical education that better align with the needs of the health care system. The authors apply several key features of the communities of practice theory to current experiential roles for students, then propose a new approach to students' clinical experiences-value-added clinical systems learning roles-that provides students with opportunities to make meaningful contributions to patient care while learning health systems science at the patient and population level. Finally, the authors discuss implications for professional role formation and anticipated challenges to the design and implementation of value-added clinical systems learning roles.

Medical student expectations from surgical education: A two-year institutional experience.

BACKGROUND: The third-year surgical rotation is the first exposure medical students have to the fundamentals of surgical education. It is known that medical students come to the surgical clerkship with preconceived ideas, many of them negative and based on prior student feedback and hearsay. METHODS: An anonymous survey was conducted of third-year medical students while on the surgical clerkship. We sought to quantify student's experiences and expectations by assessing the students' confidence levels before and after the rotation. RESULTS: Over a 26 month period from July 2013-August 2015, 250 surveys were conducted. In terms of confidence gained on the surgical rotation, students reported a statistically significant (p < 0.01) increase in confidence in fifteen different areas of interest. However, in terms of expectations, students reported discordance between anticipated experience and actual experience. Students' responses indicate that students felt confident with their knowledge of diseases; however, they desire more involvement in complex patient care and procedural skills. CONCLUSIONS: The third-year clerkship is the first exposure to surgery for many medical students. Surgical educators are tasked with providing a foundation for clinical medicine; however, students have expressed an expectation to be more involved with complex patient care and management.

Working together: Using a unique approach to evaluate an interactive and clinic-based longitudinal interprofessional education experience with 13 professions.

Interprofessional education (IPE) involving an interactive and longitudinal clinic experience at an inner-city charitable clinic from September to May 2013/2014 was evaluated. Pre-, mid-, and post-intervention data were collected from students in 13 different professions including medicine (medical and physician assistant), dentistry (dental and dental hygiene), nursing (undergraduate and clinical nurse specialist), public health, pharmacy, physical therapy, occupational therapy, nutritional sciences, speech and language pathology, and social work. To evaluate their interprofessional attitudes, students completed the TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) and Readiness for Interprofessional Learning Scale (RIPLS). They also completed a unique measure, healthcare professionals circles diagrams (HPCDs), that indicated student conceptualisation of a healthcare team caring for a complex patient, along with perception of their team's progress towards meeting patient goals. Results from the T-TAQ and RIPLS scores indicated small but significant increases from pre- to post-intervention (p = 0.005 and 0.012, respectively). Analysis of the HPCDs revealed significant increases in students' perceptions of the types of interprofessional team members, relationships, and communication between professions to provide medical care to patients (p < 0.01). Most HPCDs included pharmacists, nurses, and physicians as part of the care team at all time points. Students significantly increased their inclusion of dentistry, public health, social work, and physician assistants as members of the healthcare team from pre- to post-intervention. Implications of our data indicated the importance of IPE interventions that include not only classroom-based sessions, but actual patient care experiences within interprofessional teams. It also reinforced the importance of new and unique methods to assess IPE.

Providing context for a medical school basic science curriculum: The importance of the humanities.

INTRODUCTION: To increase students' understanding of what it means to be a physician and engage in the everyday practice of medicine, a humanities program was implemented into the preclinical curriculum of the medical school curriculum. The purpose of our study was to determine how medical students' views of being a doctor evolved after participating in a required humanities course. METHODS: Medical students completing a 16-clock hour humanities course from 10 courses were asked to respond to an open-ended reflection question regarding changes, if any, of their views of being a doctor. The constant comparative method was used for coding; triangulation and a variety of techniques were used to provide evidence of validity of the analysis. RESULTS: A majority of first- and second-year medical students (rr = 70%) replied, resulting in 100 pages of text. A meta-theme of Contextualizing the Purpose of Medicine and three subthemes: the importance of Treating Patients Rather than a Disease, Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible emerged from the data. CONCLUSIONS: Results suggest that requiring humanities as part of the required preclinical curriculum can have a positive influence on medical students and act as a bridge to contextualize the purpose of medicine.

Informed consent training improves surgery resident performance in simulated encounters with standardized patients.

BACKGROUND: Although informed consent is vital to patient-physician communication, little training is provided to surgical trainees. We hypothesized that highlighting critical aspects of informed consent would improve resident performance. METHODS: Eighty (out of 88) surgical postgraduate year 1 surgical residents were randomly assigned to one of the 2 cases (laparoscopic cholecystectomy or ventral herniorrhaphy) and instructed to obtain and document informed consent with a standardized patient (SP) followed by a didactic training session. The residents then obtained and documented informed consent with the other case with the other SP. SPs graded encounters ("Checklist"); trained raters graded notes. Repeated measures multivariate analysis of variance (MANOVA) was used to determine differences between pre- and post-training and Checklist versus "Note" scores. RESULTS: Statistically significant pre- to post differences for Note (P < .01) and Checklist (P < .01) along with significant differences between Note and Checklist (P < .01) were noted. CONCLUSIONS: Training improved surgery residents' ability to discuss and document informed consent. Despite this improvement, significant differences between discussion and documentation persisted. Documentation training is a future area for improvement.

Team cohesiveness, team size and team performance in team-based learning teams.

OBJECTIVES: The purpose of this study was to explore the relationships among variables associated with teams in team-based learning (TBL) settings and team outcomes. METHODS: We administered the National Board of Medical Examiners (NBME) Psychiatry Subject Test first to individuals and then to teams of Year three students at four medical schools that used TBL in their psychiatry core clerkships. Team cohesion was analysed using the Team Performance Scale (TPS). Bivariate correlation and linear regression analysis were used to analyse the relationships among team-level variables (mean individual TPS scores for each team, mean individual NBME scores of teams, team size, rotation and gender make-up) and team NBME test scores. A hierarchical linear model was used to test the effects of individual TPS and individual NBME test scores within each team, as well as the effects of the team-level variables of team size, team rotation and gender on team NBME test scores. Individual NBME test and TPS scores were nested within teams and treated as subsampling units. RESULTS: Individual NBME test scores and individual TPS scores were positively and statistically significantly (p < 0.01) associated with team NBME test scores, when team rotation, team size and gender make-up were controlled for. Higher team NBME test scores were associated with teams rotating later in the year and larger teams (p < 0.01). Gender make-up was not significantly associated. CONCLUSIONS: The results of an NBME Psychiatry Subject Test administered to TBL teams at four medical schools suggest that larger teams on later rotations score higher on a team NBME test. Individual NBME test scores and team cohesion were positively and significantly associated with team NBME test scores. These results suggest the need for additional studies focusing on team outcomes, team cohesion, team size, rotation and other factors as they relate to the effective and efficient performance of TBL teams in health science education.