Should I do a synthesis (i.e. literature review)?

This column is intended to address the kinds of knotty problems and dilemmas with which many scholars grapple in studying health professions education. In this article, the authors address the question of whether one should conduct a literature review or knowledge synthesis, considering the why, when, and how, as well as its potential pitfalls. The goal is to guide supervisors and students who are considering whether to embark on a literature review in education research.

Advancing anti-oppression and social justice in healthcare through competency-based medical education (CBME).

Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs - outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners' needs, teaching focused on competencies, and programmatic assessment - enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner's background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner's success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.

The ingredients of a rich entrustment decision.

Entrustment decision-making has become a topic of interest in workplace-based assessment in the health professions and is germane to the use of entrustable professional activities. Entrustment decisions stem from judgments of a trainee's competence and include the permission to act with a higher level of responsibility or autonomy and a lower level of supervision. Making entrustment decisions differs from regular assessment of trainees, which usually has no consequences beyond marking trainee progress. Studies show that clinicians generally weigh more factors in making an entrustment decision than when merely assessing trainee competence or performance without direct consequences for patient care. To synthesize the varying factors reported in literature, the authors performed a thematic analysis of key qualitative studies that investigated trainee features clinical supervisors find important when making entrustment decisions. Five themes emerged from the 13 publications: Capability (specific knowledge, skills, experience, situational awareness), Integrity (truthful, benevolent, patient-centered), Reliability (conscientious, predictable, accountable, responsible), Humility (recognizes limits, asks for help, receptive to feedback), Agency (proactive toward work, team, safety, personal development). Thoughtful entrustment decisions, made either by individual clinical supervisors or by clinical competency committees, may be enriched by taking into account these five features.

Developing a Novel 4-C Framework to Enhance Participation in Faculty Development.

Phenomenon: Universities offer a variety of voluntary faculty development to ensure quality education, but face inconsistent faculty participation. Therefore, all Dutch universities require all faculty to obtain a teaching qualification certificate. Yet, like other medical centers, University Medical Center Utrecht continued to struggle with faculty nonparticipation. It has been postulated that clinician teachers may face unique challenges with responsibilities for patient care in addition to teaching and research, challenges that cannot be overcome by merely mandating faculty development or a teaching certificate. This project was conducted to gain insight into factors that hinder faculty participation and better understand what is needed to enhance faculty engagement in their professional development as teachers. Approach: UMC Utrecht has had a teaching certificate requirement for over 20 years. In 2015-2016, we conducted a local needs assessment, gathering faculty perspectives about the teaching certification process. To convey seriousness of purpose and promote commitment to change, we formally engaged key stakeholders from the outset, obtained grant funding for the needs assessment, and had an outside consultant lead the project. Faculty who were stalled or never started were questioned via semi-structured interviews. A focus group with those actively in the process of obtaining their certificate discussed perceived challenges in the process and recommended solutions. Faculty who obtained their teaching certificate completed an anonymous evaluation form. All evaluation comments and transcripts were thematically analyzed using open and axial coding. A literature review was performed to contextualize our findings and identify potential solutions. We compared our initial themes to these findings and found key challenge/solution categories, which we subsequently developed into a novel framework. Findings from the study and literature review were organized using this framework and shared with different stakeholders, all of whom engaged in problem-solving. Ideas and potential solutions were incorporated into a final report with recommendations for improving faculty support and provided to the institutional leadership. Findings: Of 23 faculty teachers approached, 8 (34.8%) agreed to be interviewed; 7 of 25 (28.0%) participated in the focus group; and 83 of 156 (53.2%) completed the evaluation. From the transcripts and evaluation comments, three themes emerged related to context and barriers: (a) skill development versus certification; (b) workplace priorities and culture, and (c) visibility and feasibility of the teacher's role. Triangulation of these themes with the literature revealed four challenge/solution categories - Competence, Context, Community, and Career. This 4-C framework facilitated communication of findings, structured the development of an action plan in response to the findings, and assured implementation of new initiatives for faculty support beyond competence development. Insights: Simply adopting requirements for faculty development may be insufficient and even invoke resistance. Improving faculty participation in faculty development and the quality of education requires institutional attention to not just faculty Competence needs, but also the factors of Context, Community, and Career that together comprise the culture experienced by faculty teachers. With institutional buy-in and commitment to change, the 4-C framework can help focus institutional attention on existing gaps in all four domains and guide the development of comprehensive solutions.

Addressing the hidden curriculum in the clinical workplace: A practical tool for trainees and faculty.

INTRODUCTION: The hidden curriculum, commonly described in negative terms, is considered highly influential in medical education, especially in the clinical workplace. Structured approaches to address it are limited in number and scope. METHODS AND RESULTS: This paper presents a practical, value-neutral method called REVIEW (Reflecting & Evaluating Values Implicit in Education in the Workplace), to facilitate reflection and discussion on the hidden curriculum by faculty members and trainees. REVIEW approaches the hidden curriculum as a reflection of the professional microculture of a clinical team. This microculture results from collective problem solving and mutual negotiation when facing different, often conflicting, demands and interests, and their underlying values in daily clinical practice. Using this nonjudgmental conceptual framework, REVIEW employs a series of 50 culture statements that must be prioritized using Q-sort methodology, reflecting how the culture in a particular clinical context (e.g. ward or department) is perceived by faculty members and trainees. This procedure can be done individually or in groups. Most important is the resulting team discussion after the exercise - a discussion about perceptions of actual team culture and the culture desired by the team. DISCUSSION AND CONCLUSIONS: Our early experiences suggest that REVIEW can be a useful tool for addressing the hidden curriculum.

The Feasibility of Longitudinal Patient Contacts in a Large Medical School.

PROBLEM: Longitudinal patient contacts are being implemented worldwide as a way to enhance a patient-centered orientation among medical students. In large medical schools, longitudinal integrated clerkships may not be feasible, so other ways must be sought to expose students to prolonged contact with patients. INTERVENTION: Medical students were attached to a family practice and assigned a panel of 4 patients to follow over the 3 years of their clinical training. Their role was that of companion on the patient's medical journey. The program consisted of several encounters, joining the patient in the medical setting for significant events, and written assignments. This intervention was piloted with 35 students. We describe our experiences from the 1st pilot year of this program. CONTEXT: The intervention was performed with 3rd-year students-of a 6-year curriculum-at a large medical school in the Netherlands. OUTCOME: Finding enough patients per practice was feasible. On the whole, students fulfilled the program's expectations regarding frequency of patient encounters and assignments. The most frequent problems encountered by the students were uncertainty about their role and setting boundaries in their contact with the patients. They needed more preceptor supervision and coaching than they received. LESSONS LEARNED: For junior students, close and structured supervision led by the faculty is necessary to help them navigate and learn from a panel of patients. Students need guidance about what role they should take on and on how to manage both their own and their patient's expectations. Guided reflection is necessary to help students give meaning to their experiences with patients.

Twelve tips for the implementation of EPAs for assessment and entrustment decisions.

The concept of entrustable professional activities (EPAs) reframes the approach to assessment in competency-based medical education. Key to this concept is the linking of assessment to decision making about entrusting learners with clinical responsibilities. Based on recent literature and the authors' experiences with implementing EPAs, this article provides practical recommendations for how to implement EPAs for assessment and entrustment decisions in the workplace. Tips for supervising clinicians include talking to learners about trust, using EPA descriptions to guide learning and teaching, providing learners with greater ad hoc responsibilities, using EPAs to identify/create opportunities for assessment and feedback, including case-based discussions and acknowledging gut feelings about learner readiness for more autonomy. Tips for curriculum leaders entail enabling the trust development, applying trust decisions at all levels of the supervision scale, employing all available information sources for entrustment, empowering learner ownership of the assessment process and using technology for learner tracking and program evaluation.

The Health Professions Education Pathway: Preparing Students, Residents, and Fellows to Become Future Educators.

PROBLEM: Training the next generation of health professionals requires leaders, innovators, and scholars in education. Although many medical schools and residencies offer education electives or tracks focused on developing teaching skills, these programs often omit educational innovation, scholarship, and leadership and are narrowly targeted to one level of learner. INTERVENTION: The University of California San Francisco created the Health Professions Education Pathway for medical students, residents, and fellows as well as learners from other health professional schools. The Pathway applies the theoretical framework of communities of practice in its curricular design to promote learner identity formation as future health professions educators. It employs the strategies of engagement, imagination, and alignment for identity formation. CONTEXT: Through course requirements, learners engage and work with members of the educator community of practice to develop the knowledge and skills required to participate in the community. Pathway instructors are faculty members who model a breadth of educator careers to help learners imagine personal trajectories. Last, learners complete mentored education projects, adopting scholarly methods and ethics to align with the broader educator community of practice. OUTCOME: From 2009 to 2014, 117 learners participated in the Pathway. Program evaluations, graduate surveys, and web-based searches revealed positive impacts on learner career development. Learners gained knowledge and skills for continued engagement with the educator community of practice, confirmed their career aspirations (imagination), joined an educator-in-training community (engagement/imagination), and disseminated via scholarly meetings and peer-reviewed publications (alignment). LESSONS LEARNED: Learners identified engagement with the learner community as the most powerful aspect of the Pathway; it provided peer support for imagining and navigating the development of their dual identities in the clinician and educator communities of practice. Also important for learner success was alignment of their projects with the goals of the local educator community of practice. Our community of practice approach to educator career development has shown promising early outcomes by nurturing learners' passion for teaching; expanding their interest in educational leadership, innovation, and scholarship; and focusing on their identity formation as future educators.

Students' goal orientations, perceptions of early clinical experiences and learning outcomes.

CONTEXT: Workplace learning is optimised when learners engage in the activities of the workplace; learner engagement is influenced by workplace affordances and learner agency. Learner agency can be operationalised through achievement goal theory, which explains that students can have different goal orientations as they enter learning situations: mastery (learn and improve), performance approach (demonstrate competence) or performance-avoid (avoid demonstrating incompetence). Mastery-orientated, compared with performance-orientated, students approach curricular experiences as opportunities for developing rather than demonstrating competence. This study explored the relationships among students' achievement goal orientations, workplace affordances and learning outcomes in the context of early clinical experiences. METHODS: Students who completed their preclerkship curricula at four medical schools answered a questionnaire about their personal goal orientation and the perceived goal structure and workplace affordances of their preceptorship experiences. All items used a 5-point scale (1 = strongly disagree/not at all true, 5 = strongly agree/very true). Students were evaluated by their preceptors and completed standardised-patient exams at the end of their pre-clerkship curricula. Analyses included descriptive statistics and mediation analysis. RESULTS: Of 517 students, 296 (57.3%) responded and 253 (85.5%) had linked performance data. Student goal orientation means were: mastery, mean = 4.27 (SD = 0.65); performance-approach, 2.41 (0.76); performance-avoid, 2.84 (0.88). Student goal orientation and performance on preceptor evaluations (PEval) or standardised-patient exams (SPExam) were not significantly related. Perceptions of a mastery-structured curriculum and inviting workplace were associated with higher SPExam (ß = 0.28, p = 0.02) and PEval (ß = 0.51, p = 0.00) scores, respectively. Student mastery goal orientation was positively associated with perceptions of a mastery-structured curriculum (ß = 0.59, p = 0.00) and positive workplace affordances (ß = 0.25-0.29, p ≤ 0.01). CONCLUSIONS: Students held a predominant mastery goal orientation towards their early clinical experiences. Mastery-orientated students perceived preceptorships as mastery-structured with positive workplace affordances, and those perceiving a mastery-structured or inviting preceptorship performed better. Clinical experiences should be structured to emphasise learning rather than demonstration of skills to promote learning outcomes.

An interview study of how clinical teachers develop skills to attend to different level learners.

PURPOSE: One clinical teaching challenge is the engagement of learners at different levels. Faculty development offerings mostly address general strategies applicable to all learners. This study examined how clinical faculty members develop the skills to work with different level learners. METHODS: We conducted semi-structured interviews with medical school faculty members identified as excellent clinical teachers teaching multiple levels of learners. They discussed how they developed their approach to teaching different level learners and how their teaching evolved over time. We performed thematic analysis of the interview transcripts using open and axial coding. RESULTS: We interviewed 19 faculty members and identified three themes related to development of teaching practices: teacher agency and work-based learning of teaching strategies, developmental trajectory of clinical teachers, and interplay between clinical confidence and teaching skills. Faculty members were proactive in using on-the-job experiences to develop their teaching practices. Their teaching practices followed a developmental trajectory towards learner centeredness, and this evolution was associated with the development of clinical skills and confidence. CONCLUSIONS: Learning skills to teach multi-level learners requires workplace learning. Faculty development should include workplace learning opportunities and use a developmental approach that accounts for the trajectory of teaching as well as clinical skills attainment.

Sequencing learning experiences to engage different level learners in the workplace: An interview study with excellent clinical teachers.

PURPOSE: Learning in the clinical workplace can appear to rely on opportunistic teaching. The cognitive apprenticeship model describes assigning tasks based on learner rather than just workplace needs. This study aimed to determine how excellent clinical teachers select clinical learning experiences to support the workplace participation and development of different level learners. METHODS: Using a constructivist grounded theory approach, we conducted semi-structured interviews with medical school faculty identified as excellent clinical teachers teaching multiple levels of learners. We explored their approach to teach different level learners and their perceived role in promoting learner development. We performed thematic analysis of the interview transcripts using open and axial coding. RESULTS: We interviewed 19 clinical teachers and identified three themes related to their teaching approach: sequencing of learning experiences, selection of learning activities and teacher responsibilities. All teachers used sequencing as a teaching strategy by varying content, complexity and expectations by learner level. The teachers initially selected learning activities based on learner level and adjusted for individual competencies over time. They identified teacher responsibilities for learner education and patient safety, and used sequencing to promote both. CONCLUSIONS: Excellent clinical teachers described strategies for matching available learning opportunities to learners' developmental levels to safely engage learners and improve learning in the clinical workplace.

Legitimate workplace roles and activities for early learners.

OBJECTIVES: Given the calls for earlier student engagement in clinical experiences, educators are challenged to define roles for pre-clerkship students that enable legitimate participation in clinical practice. This study aimed to determine the student roles and activities, as well as the clinic characteristics, that allow early student engagement within a specific clinical experience. METHODS: The authors conducted semi-structured interviews in December 2011 and January 2012 with a purposive sample of medical student and faculty volunteers at student-run clinics (SRCs). They were asked to discuss and compare student roles in SRCs with those in the core curriculum. An inductive approach and iterative process were used to analyse the interview transcripts. Themes identified from initial open coding were organised using the sensitising concepts of workplace learning and communities of practice and subsequently applied to code all transcripts. RESULTS: A total of 22 medical students and four faculty advisors were interviewed. Thematic analysis revealed pre-clerkship student roles in direct patient care (patient triage, history and physical examinations, patient education, laboratory and immunisation procedures) and in clinic management (patient follow-up, staff management, quality improvement). Students took ownership of patients and occupied central roles in the function of the clinic, with faculty staff serving as peripheral resources. Clinic-related features supporting this degree of legitimate participation included defined scopes of practice, limited presenting illnesses, focused student training, and clear protocols and operations manuals. CONCLUSIONS: Pre-clerkship students are capable of legitimately participating in patient care experiences to an extent not usually available to them. The SRC represents one example of how early clinical experiences in the core curriculum might be transformed through the provision of patient care activities of narrow scope.

Screening for Food Insecurity: A Curriculum for Medical Students.

Introduction: Food insecurity (FI) is defined as a lack of access to enough food for an active, healthy life. We sought to determine how a longitudinal FI screening curriculum impacts medical students' knowledge, attitudes, and behavior in screening for FI. Methods: This was a prospective, single-institution study. The curriculum consisted of three components completed over 3 years. We administered a survey to the intervention cohort before and after the curriculum and analyzed their written reflections. We also evaluated whether students screened for FI during an objective structured clinical exam (OSCE) and compared their performance to a control cohort, which did not receive the curriculum. Results: Preintervention, students felt screening for FI was important for physicians to do with their patients, but most felt uncomfortable addressing it in clinical settings. Postintervention, there was a statistically significant increase in mean scores for knowledge questions (45.24% vs 74.74%, P<.001, pre- and postintervention, respectively). Students also felt more confident in their abilities to screen and follow up about FI. Additionally, compared to the control cohort, the intervention cohort screened for FI more often during their OSCE (28.21% vs 10.71%, P<.001). Conclusion: A longitudinal curriculum using minimal curricular time can improve students' knowledge, attitudes, and behavior when screening for FI. Students who received the curriculum were more likely to recognize the need for and perform FI screening. Based on these findings, we anticipate that the curriculum will increase the likelihood of students identifying, screening for, and intervening in cases of FI in future clinical encounters.

The Consequences of Step 2 Clinical Skills Examination Discontinuation for Medical Schools and Sustainability Plans for Clinical Skills Assessment.

PURPOSE: Comprehensive clinical skills examinations using standardized patients are widely used to assess multiple physician competencies. However, these exams are resource intensive. With the discontinuation of the Step 2 Clinical Skills (CS) exam in 2021, how medical schools will change their approaches to comprehensive clinical skills exams is unknown. This study explores school responses to this change and future directions of comprehensive clinical skills exams using the program sustainability framework. METHOD: This cross-sectional, descriptive study surveyed medical school curriculum deans at 150 Liaison Committee on Medical Education-accredited U.S. medical schools from September to October 2021. The 30-question survey included questions about medical school and participant role, current comprehensive clinical skills exams, sustainability dimensions, and challenges and future directions. Descriptive statistics were used to characterize responses, and content analysis was used to identify themes in the open-ended responses. RESULTS: Educators at 75 of 150 institutions (50%) responded. Sixty-three respondents (84%) reported conducting a comprehensive clinical skills exam. The comprehensive clinical skills exam assessed readiness for graduation (51 [81%]), provided feedback for students (49 [78%]), evaluated curricula (38 [60%]), provided information for medical student performance evaluation or communication with residency (10 [16%]), and assessed other factors (6 [10%]), including preparation for Step 2 CS in the past and readiness for advancement to fourth year of medical school (multiple responses were allowed). Factors facilitating sustainability included sufficient funding to continue the exam (55 [87%]) and the belief that clinical skills assessment in medical school is now more important after discontinuation of the Step 2 CS exam (55 [87%]). Challenges to sustainability included organizational capacity and limited interinstitutional collaboration. CONCLUSIONS: Educators remain committed to the purpose of comprehensive clinical skills exams. Adapting to changed licensing requirements while sustaining clinical skills exams enables innovation and improvement in assessment of clinical competence.

When students' words hurt: 12 tips for helping faculty receive and respond constructively to student evaluations of teaching.

Student evaluations of curricular experiences and instructors are employed by institutions to obtain feedback and guide improvement. However, to be effective, evaluations must prompt faculty action. Unfortunately, evaluative comments that engender strong reactions may undermine the process by hindering innovation and improvement steps. The literature suggests that faculty interpret evaluation feedback as a judgment not just on their teaching ability but on their personal and professional identity. In this context, critical evaluations, even when constructively worded, can result in disappointment, hurt, and shame. The COVID pandemic has challenged institutions and faculty to repeatedly adapt curricula and educational practices, heightening concerns for faculty burnout. In this context, the risk of 'words that hurt' is higher than ever. This article offers guidance for faculty and institutions to support effective responses to critical feedback and ameliorate counterproductive effects of learner evaluations.

The Impact on Medical Student Stress in Relation to a Change in USMLE Step 1 Examination Score Reporting to Pass/Fail.

The United States Medical Licensing Examination (USMLE) Step 1 was designed to be a benchmark measure of knowledge and has been used heavily in the residency application process. Step 1 has moved from 3-digit scoring to a pass/fail scoring system, in part to decrease the stress associated with the exam. Emerging literature suggests that this transition has led to other stresses for students. Our study compared student stress levels, both overall and in relation to Step 1, leading up to the exam between a scored cohort and pass/fail cohort. We administered to each cohort a 14-item survey that included demographics, the PSS-4 stress scale, and 6 other potential stressors. Data was analyzed using two-tailed t test for independent means and analysis of variance. We found that while there was no difference in general overall stress between the students who took Step 1 for a score and students who took Step 1 pass/fail, we did see differences in stress related to the Step 1 exam. Step 1 stress was significantly lower for the pass/fail cohort than the score cohort during the second year of medical education leading up to the exam. However, this difference in Step 1 stress between the cohorts disappeared by the dedicated study period immediately before the exam. The change in scoring appears to have decreased stress specifically related to Step 1, but this reduction was not sustained as students entered their study period to prepare for Step 1.

Faculty and Student Perceptions of Unauthorized Collaborations in the Preclinical Curriculum: Student or System Failure?

PURPOSE: Unauthorized collaboration among medical students, including the unauthorized provision of assistance and sharing of curricular and assessment materials, is a reported problem. While many faculty view such sharing as academic dishonesty, students do not always perceive these behaviors as problematic. With the trend toward more small-group and team-based learning and the proliferation of resource-sharing and online study aids, collaboration and sharing may have become a student norm. This multi-institutional, qualitative study examined faculty and student perceptions of and student motivations for unauthorized collaboration. METHOD: Using a constructivist approach, the authors conducted scenario-prompted semistructured interviews with faculty and students in the preclinical curriculum. Participants were asked to reflect on scenarios of unauthorized collaboration and discuss their perceptions of student motivation and the influence of personal or environmental factors. The authors performed inductive thematic analysis of the interview transcripts using open and axial coding followed by abstraction and synthesis of themes. RESULTS: Twenty-one faculty and 16 students across 3 institutions were interviewed in 2021. There was variation in perceptions among faculty and among students, but little variation between faculty and students. Both participant groups identified the same 3 areas of tension/themes: faculty/curriculum goals vs student goals, inherent character traits vs modifiable behavioral states, and student relationships with their peer group vs their relationships with the medical education system. Student behaviors were perceived to be influenced by their environment and motivated by the desire to help peers. Participants suggested cultivating trust between students and the education system, environmental interventions, and educating students about acceptable and unacceptable behaviors to prevent unauthorized collaboration. CONCLUSIONS: Given the various tensions and positive motivations behind unauthorized collaborations, institutions should consider explicitly preparing students to make thoughtful decisions when faced with competing priorities in addition to developing mitigation strategies that address the environment and its interactions with students.

Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions.

Introduction: Self-regulated learning is a cyclical process of forethought, performance, and self-reflection that has been used as an assessment tool in medical education. No prior studies have evaluated SRL processes for answering multiple-choice questions (MCQs) and most evaluated one or two iterations of a non-MCQ task. SRL assessment during MCQs may elucidate reasons why learners are successful or not on these questions that are encountered repeatedly during medical education. Methods: Internal medicine clerkship students at three institutions participated in a SRL microanalytic protocol that targeted strategic planning, metacognitive monitoring, causal attributions, and adaptive inferences across seven MCQs. Responses were transcribed and coded according to previously published methods for microanalytic protocols. Results: Forty-four students participated. In the forethought phase, students commonly endorsed prioritizing relevant features as their diagnostic strategy (n = 20, 45%) but few mentioned higher-order diagnostic reasoning processes such as integrating clinical information (n = 5, 11%) or comparing/contrasting diagnoses (n = 0, 0%). However, in the performance phase, students' metacognitive processes included high frequencies of integration (n = 38, 86%) and comparing/contrasting (n = 24, 55%). In the self-reflection phase, 93% (n = 41) of students faulted their management reasoning and 84% (n = 37) made negative references to their abilities. Less than 10% (n = 4) of students indicated that they would adapt their diagnostic reasoning process for these questions. Discussion: This study describes in detail student self-regulatory processes during MCQs. We found that students engaged in higher-order diagnostic reasoning processes but were not explicit about it and seldom reflected critically on these processes after selecting an incorrect answer. Self-reflections focused almost exclusively on management reasoning and negative references to abilities which may decrease self-efficacy. Encouraging students to identify and evaluate diagnostic reasoning processes and make attributions to controllable factors may improve performance.