Online Learning in Medical Student Clerkship: A Survey of Student Perceptions and Future Directions.

Background The coronavirus disease 2019 (COVID-19) pandemic had a major impact on medical education with clerkship students abruptly removed from clinical activities in 2020 and hastily immersed in online learning to maintain medical education. In 2022, students returned to in-person clinical experiences, but synchronous learning sessions continued online with extensive use of asynchronous online resources. This change offers a unique opportunity to gather information about students' perspectives regarding the acceptability and effectiveness of online learning strategies. This study aims to explore the clerkship student experience with the integration of online learning and in-person learning into formalized educational sessions in clerkship. Methodology The authors administered an online survey to clerkship students at the Cumming School of Medicine at the University of Calgary, Canada in spring 2022. The survey consisted of primarily Likert-style questions to explore the perceived effectiveness of various online learning strategies. Results are reported as the proportion selecting "quite effective" or "extremely effective." Results A total of 89 students responded to the survey (57.4% of graduating class). For synchronous online learning, case-based learning was perceived as the most effective teaching strategy (61.8%), and audience response systems were the most effective strategy for improving audience engagement (70.1%). For asynchronous online learning, interactive cases (84.9%) and student-developed online study guides (83.6%) were perceived as the most effective. Students held varying perceptions regarding how online learning impacted their well-being. When considering future clerkship curricula, the majority of clerkship students preferred a blend of in-person and online learning. Conclusions This study identified that most clerkship students prefer a hybrid of in-person and online learning and that ideal online learning curricula could include case-based learning, audience response systems, and a variety of asynchronous learning resources. These results can guide curriculum development and design at other medical institutions.

Observational Study of Conformity in Yet Another Medical Learning Environment: Conformity to Preceptors During High-Fidelity Simulation.

Purpose: Altering one's behavior to comply with inaccurate suggestions made by others (i.e., conformity) has been studied since the 1950s. Although several studies have documented its occurrence in medical education, it has yet to be examined in a high-fidelity simulation environment. It was hypothesized that a large majority of learners would conform to a preceptor. Patients and Methods: A total of 42 student dyads (a medical student paired with a resident) participated in one of four clinical scenarios to manage the diagnosis and treatment of a simulated patient encounter. Once the learners became familiar with the patient's case, a preceptor entered the simulation, offered an equivocal suggestion about diagnosis or management, and then left. Two raters observed the video recordings of how the learners managed the case after this suggestion was made. The nature of these interactions was also documented. Results: Sixteen (38.10%) of the 42 medical student dyads conformed to the equivocal information presented by the preceptors. Observations of these interactions showed that all of the medical students conformed to the residents, but not all of the medical students conformed to the preceptors. Conclusion: Many learners conform to preceptors by acting on their equivocal suggestion when managing a patient case during high-fidelity simulation.

Communication in the conversation between preceptors and physicians-in-training during simulation: what is not said.

BACKGROUND: There is an abundance of published communication models, but few explicate how professional conversation may include the communication of some information but exclude the sharing of one's inner thoughts and feelings. This conceptualization of communication was applied to guide our understanding of how medical learners interact with preceptors at the bedside in a high-fidelity simulation when managing a patient case. METHODS: A total of 84 medical learners (42 residents and 42 medical students) participated in a high-fidelity simulation. After they interacted with the patient for about 10 min, a preceptor entered and offered an equivocal or questionable recommendation about diagnosis or treatment. This type of recommendation was designed to trigger a difficult conversation that would create an opportunity for the learners to share facts, thoughts, points of view, and feelings about the patient with the preceptor. The preceptor left the room, and the learners completed their assessment once they made a diagnosis and treatment recommendations. Two raters independently coded the communication between the preceptor and learners by independently watching video recordings. RESULTS: Of the three types of communication styles identified in the model, the majority of learners (n = 56, 66.70%) engaged in a muted conversation where they shared little or no clarification of facts about the patient's case, their feelings or thoughts, nor did they explore their preceptor's point of view. CONCLUSIONS: Learners may not feel comfortable exploring or expressing thoughts and feelings in front of their preceptors. We recommend that preceptors directly engage learners in conversation.

Implementation of a Humanoid Robot as an Innovative Approach to Child Life Interventions in a Children's Hospital: Lofty Goal or Tangible Reality?

INTRODUCTION: This study reports the findings on how Child life specialists (CLSs) implemented an innovative approach to providing therapeutic support to pediatric patients. METHODS: Part of a larger study that uncovered themes about CLSs' experiences while working with MEDi®, this study reports the reflections that CLSs have about the process of implementation. Seven CLSs participated in semi-structured interviews. Content analysis was conducted on interview data and three themes were generated. RESULTS: The first was in regards to the adoption process whereby CLS challenges, successes, and surprises were revealed. Second, CLSs explained how using MEDi® aligned with the roles and responsibilities of their profession. The third area of understanding was in CLS explanation of the friendly emotional impact MEDi® seems to have on the hospital environment. CONCLUSION: Child life specialists are encouraged to use the MEDi® robot to support children at the bedside.

Children's Pain During IV Induction: A Randomized-Controlled Trial With the MEDi® Robot.

OBJECTIVE: This study examined the impact of a humanoid robot (MEDi®) programmed to teach deep breathing as a coping strategy, on children's pain and fear as primary and secondary outcomes, respectively, during intravenous (IV) line placement. The completion of IV induction was also examined as an exploratory outcome. METHODS: In this randomized controlled, two-armed trial, 137 children (4-12 years) were recruited in Short Stay Surgery at a tertiary pediatric hospital. Patients were randomly assigned to standard care (SC) with Ametop© only (N = 60) or SC and robot-facilitated intervention (N = 59) before induction. Pain and fear before, during, and after IV insertion were rated by patients and observers. RESULTS: No significant differences were found between groups and there were no changes over time for pain or fear (ps > .05). Exploratory analyses show that patients in the MEDi® group were 5.04 times more likely to complete IV induction, compared to SC, Fisher's exact test: X2 (1) = 4.85, p = .04, φc = 0.22, odds ratio = 5.04, 95% CI [1.06, 24.00]. CONCLUSION: This study was the first to examine children's IV induction experience when provided MEDi® support. Reasons for nonsignificance, limitations, and research suggestions were made.

Twelve tips for using simulation to teach about conformity behaviors in medical education.

Decision-making at different moments in patient care is fraught with potential latent threats. Social influence is one such threat that is increasingly being reported in healthcare and medical education. While different teaching modalities might bring attention to the various ways in which learners conform during clinical decision-making, simulation stands alone as a robust experiential approach to trigger and influence behaviors of learners. Our article provides 12 tips for teaching about conformity using simulation as a modality. This article contributes to medical education because of its focus on a variety of nuances and adaptations required in the simulation scenario design and reflective feedback when teaching about the impact of social influence on clinical decision making. While such a learning outcome presents an unusual challenge for teachers and learners, the ultimate outcome remains the same - that is - to provide meaningful learning while holding honesty and safety of our learners as core values.

Children's Fear and Pain During Medical Procedures: A Quality Improvement Study With a Humanoid Robot.

BACKGROUND: Pediatric patients undergo a variety of painful medical procedures. PURPOSE: The goal of this quality improvement study was to introduce a humanoid robot (MEDi®) programmed with strategies, such as distraction and deep breathing, at inpatient and outpatient units to determine any preliminary effects on children's pain and fear during medical procedures. METHODS: A nonrandomized two-group pre- and posttest design was used to compare pain and fear of children before and after intervention versus standard care. A total of 46 children aged 2-15 years undergoing various medical procedures in a pediatric hospital, and their parents completed the Children's Fear Scale and the Faces Pain Scale-Revised. The former was used both before and after the procedure, while the latter only after the procedure. RESULTS: Children (n = 18), who interacted with the robot before and during a procedure, and their parents reported significantly lower levels of fear and pain than did children (n = 28) and their parents in standard care, ps < .05. CONCLUSIONS: The use of a humanoid robot programmed with psychological strategies to support coping may enhance children's experiences of care for pain management.

Using the MEDiPORT humanoid robot to reduce procedural pain and distress in children with cancer: A pilot randomized controlled trial.

BACKGROUND: Subcutaneous port needle insertions are painful and distressing for children with cancer. The interactive MEDiPORT robot has been programmed to implement psychological strategies to decrease pain and distress during this procedure. This study assessed the feasibility of a future MEDiPORT trial. The secondary aim was to determine the preliminary effectiveness of MEDiPORT in reducing child pain and distress during subcutaneous port accesses. METHODS: This 5-month pilot randomized controlled trial used a web-based service to randomize 4- to 9-year-olds with cancer to the MEDiPORT cognitive-behavioral arm (robot using evidence-based cognitive-behavioral interventions) or active distraction arm (robot dancing and singing) while a nurse conducted a needle insertion. We assessed accrual and retention; technical difficulties; outcome measure completion by children, parents, and nurses; time taken to complete the study and clinical procedure; and child-, parent-, and nurse-rated acceptability. Descriptive analyses, with exploratory inferential testing of child pain and distress data, were used to address study aims. RESULTS: Forty children were randomized across study arms. Most (85%) eligible children participated and no children withdrew. Technical difficulties were more common in the cognitive-behavioral arm. Completion times for the study and needle insertion were acceptable and >96% of outcome measure items were completed. Overall, MEDiPORT and the study were acceptable to participants. There was no difference in pain between arms, but distress during the procedure was less pronounced in the active distraction arm. CONCLUSION: The MEDiPORT study appears feasible to implement as an adequately-powered effectiveness-assessing trial following modifications to the intervention and study protocol. ClinicalTrials.gov NCT02611739.

Impact of peer pressure on accuracy of reporting vital signs: An interprofessional comparison between nursing and medical students.

The hierarchical relationship between nursing and medicine has long been known, yet its direct influence on procedural tasks has yet to be considered. Drawing on the theory of conformity from social psychology, we suggest that nursing students are likely to report incorrect information in response to subtle social pressures imposed by medical students. Second-year medical and third-year nursing students took vital signs readings from a patient simulator. In a simulation exercise, three actors, posing as medical students, and one nursing student participant all took a total of three rounds of vital signs on a high-fidelity patient simulator. In the first two rounds the three actors individually stated the same correct vital signs values, and on the third round the three actors individually stated the same incorrect vital sign values. This same procedure was repeated with actors posing as nursing students, and one medical student. A two-way analysis of variance (ANOVA) revealed that nursing student participants (M = 2.84; SD = 1.24) reported a higher number of incorrect vital signs than did medical student participants (M = 2.13; SD = 1.07), F (1,100) = 5.51, p = 0.021 (Cohen's d = 0.61). The study indicated that social pressure may prevent nursing students from questioning incorrect information within interprofessional environments, potentially affecting quality of care.

Humanoid robotics in health care: An exploration of children's and parents' emotional reactions.

A new non-pharmacological method of distraction was tested with 57 children during their annual flu vaccination. Given children's growing enthusiasm for technological devices, a humanoid robot was programmed to interact with them while a nurse administered the vaccination. Children smiled more often with the robot, as compared to the control condition, but they did not cry less. Parents indicated that their children held stronger memories for the robot than for the needle, wanted the robot in the future, and felt empowered to cope. We conclude that children and their parents respond positively to a humanoid robot at the bedside.

The good and bad of group conformity: a call for a new programme of research in medical education.

CONTEXT: Given that a significant portion of medical education occurs in various social settings (small groups, large classes, clinical environments), it is critical to examine how group members interact. One type of influence on these interactions is conformity, whereby an individual changes his or her own behaviour to match incorrect responses of others in a group. Conformity to peer pressure has been replicated in experimental research conducted in many countries over the last 60 years. There is newly emerging empirical evidence of this effect in medical education, suggesting that subtle motivations and pressures within a group may prevent students from challenging or questioning information that seems incorrect. OBJECTIVES: This narrative review aims to present an overview of theory and findings in research into conformity in the fields of social psychology, business, sociology and aviation theory to demonstrate its direct relevance to medical education and the health professions. METHODS: We searched online databases (MEDLINE, PubMed, PsycINFO and ProQuest) from the University of Calgary catalogue. We also searched citations in articles reviewed and references provided by colleagues. We limited our narrative review to publications released between 1950 and 2012. RESULTS: Group conformity behaviour may be one of a number of communication challenges associated with interprofessional care, and may represent a factor contributing to the burden of adverse events. This paper calls for a new programme of research into conformity in medical education that provides systematic empirical evidence of its relevance and applications in education, health care and practice. CONCLUSIONS: This review reveals decades of anecdotal and empirical evidence that conformity is a pervasive phenomenon across disciplines. Further research is needed to elucidate which situations pose the greatest risk for the occurrence of conformity, how to manage it in practice and its implications for patient safety.

Accuracy of portrayal by standardized patients: results from four OSCE stations conducted for high stakes examinations.

BACKGROUND: The reliability in Objective Structured Clinical Exams (OSCEs) is based on variance introduced due to examiners, stations, items, standardized patients (SP), and the interaction of one or more of these items with the candidates. The impact of SPs on the reliability has not been well studied. Accordingly, the main purpose of the present study was to assess the accuracy of portrayal by standardized patients. METHODS: Four stations from a ten station high-stakes OSCE were selected for video recording. Due to the large number of candidates to be evaluated, the OSCE was administered using four assessment tracks. Four SPs were trained for each case (n = 16). Two physician assessors were trained to assess the accuracy of SP portrayal using a station-specific instrument based on the station guidelines. For the items with disagreement a third physician was asked to review and the mode was used for analysis. Each instrument included case-specific items on verbal and physical portrayal using a 3-point rating scale ("yes", "yes, but" and "not done"). The physician assessors also scored each SP on their overall performance based on a 5-item anchored global rating scale ("very poor", "poor", "ok", "good", and "very good"). SPs at location 1 were trained by one trainer and SPs at location 2 had another trainer. All SPs were employed in a high-stakes OSCE for at least the second time. RESULTS: The reliability of rating scores ranged from Cronbach's alpha of .40 to .74. Verbal portrayal by SPs did not significantly differ for most items; however, the facial expressions of the SPs differed significantly (p < .05). An emergency management station that depended heavily on SPs physical presentation and facial expressions differed between all four SPs trained for that station. CONCLUSIONS: Variation of trained SP portrayal of the same station across different tracks and at different times in OSCE may contribute substantial error to OSCE assessments. The training of SPs should be strengthened and constantly monitored during the exam to ensure that the examinees' scores are a true reflection of their competency and devoid of exam errors.

Cross-cultural construct validity study of professionalism of Vietnamese medical students.

BACKGROUND: Although many studies have made efforts to define and assess medical professionalism, few have addressed issues of construct validity. PURPOSES: The purpose of this article is to explore further construct validity of medical professionalism employing exploratory and confirmatory factor analysis. METHODS: The 32-item instrument by the American Board of Internal Medicine (ABIM) was adapted to assess the perceptions on medical professionalism of Vietnamese medical students. A sample of 1,196 (487 first-year, 341 third-year, 368 sixth-year) medical students participated voluntarily in the completion of the instrument. The data were randomly divided into three samples to assess the construct validity of medical professionalism by empirically deriving and confirming a model of professionalism. RESULTS: Exploratory and confirmatory factor analytic techniques resulted in a six-factor well-fitting model with a comparative fit index of .963 and root mean square error approximation of .029, 90% confidence interval [016, .039]: integrity, social responsibility, professional practice habits, ensuring quality care, altruism, and self-awareness. Social responsibility was perceived least important, and self-awareness was perceived most important by Vietnamese medical students. These constructs of medical professionalism were relatively similar with those found in Taiwanese medical students and the ABIM definitions but with some Vietnamese cultural differences. CONCLUSIONS: Although the results confirm that medical professionalism is a somewhat culturally sensitive construct, it nonetheless has many elements of medical professionalism that are universal. Future research should be conducted to test the generalizability of our six-factor model of professionalism with various samples (e.g., residents, physicians), cultures, and language groups.

Simulation-based learning combined with debriefing: trainers satisfaction with a new approach to training the trainers to teach neonatal resuscitation.

BACKGROUND: Prompt initiation of appropriate neonatal resuscitation skills is critical for the neonate experiencing difficulty transitioning to extra-uterine life. The use of simulation training is considered to be an indispensable tool to address these challenges. Research has yet to examine the effectiveness of simulation and debriefing for preparation of trainers to train others on the use of simulation and debriefing for neonatal resuscitation. This study determines the degree to which experienced NRP instructors or instructor trainers perceived simulation in combination with debriefing to be effective in preparing them to teach simulation to other health care professionals. METHODS: Participants' perceptions of knowledge, skills, and confidence gained following a neonatal resuscitation workshop (lectures; scenario development and enactment; video recording and playback; and debriefing) were determined using a pre-post test questionnaire design. Questionnaire scores were subjected to factor and reliability analyses as well as pre- and post-test comparisons. RESULTS: A total of 17 participants completed 2 questionnaires. Principal component extraction of 18 items on the pre-test questionnaire resulted in 5 factors: teamwork, ability to run a simulation, skills for simulation, recognizing cues for simulation and ability to debrief. Both questionnaire scores showed good reliability (α: 0.83 - 0.97) and factorial validity. Pre- and post-test comparisons showed significant improvements in participants' perceptions of their ability to: conduct (as an instructor) a simulation (p < .05, η² .47); participate in a simulation (p < .05, η² .45); recognize cues (p < .05, η² .35); and debrief (p < .05, η² .41). CONCLUSIONS: Simulation training increased participants' perceptions of their knowledge, skills, and confidence to train others in neonatal resuscitation.

Reducing children's pain and distress towards flu vaccinations: a novel and effective application of humanoid robotics.

OBJECTIVE: Millions of children in North America receive an annual flu vaccination, many of whom are at risk of experiencing severe distress. Millions of children also use technologically advanced devices such as computers and cell phones. Based on this familiarity, we introduced another sophisticated device - a humanoid robot - to interact with children during their vaccination. We hypothesized that these children would experience less pain and distress than children who did not have this interaction. METHOD: This was a randomized controlled study in which 57 children (30 male; age, mean±SD: 6.87±1.34 years) were randomly assigned to a vaccination session with a nurse who used standard administration procedures, or with a robot who was programmed to use cognitive-behavioral strategies with them while a nurse administered the vaccination. Measures of pain and distress were completed by children, parents, nurses, and researchers. RESULTS: Multivariate analyses of variance indicated that interaction with a robot during flu vaccination resulted in significantly less pain and distress in children according to parent, child, nurse, and researcher ratings with effect sizes in the moderate to high range (Cohen's d=0.49-0.90). CONCLUSION: This is the first study to examine the effectiveness of child-robot interaction for reducing children's pain and distress during a medical procedure. All measures of reduction were significant. These findings suggest that further research on robotics at the bedside is warranted to determine how they can effectively help children manage painful medical procedures.

Conformity of behaviors among medical students: impact on performance of knee arthrocentesis in simulation.

Although the development of collaborative relationships is considered a requirement for medical education, the functioning of these relationships may be impaired by a well-documented social-psychological phenomenon known as group conformity. The authors hypothesized that students would insert a needle into an incorrect location relative to the patella when performing a knee arthrocentesis if they believed that their peers had also inserted a needle in the same incorrect location. This was a randomized controlled study conducted in 2011 with 60 medical students (24 male; 40.0 %) who were randomly assigned to either using a knee model that had a skin with holes left by peers inserting needles in the wrong location, or a knee with no marks in the skin. Each student's aspiration site was measured with a fibreglass ruler to determine whether it was correctly located within the superior third, 1 cm medial to the patella. The researchers determined that students who used the marked skin were more likely to insert the needle in the incorrect location compared to those who used the clean skin (n = 31, 86.11 vs. n = 14, 58.33 %), Fisher's exact test (1) = 5.93, p < 0.05, Cramer's ϕ = 0.31. This study demonstrates incorrect performance of the knee arthrocentesis procedure in simulation when students use a damaged model, which may be due to conformity. It suggests that further research on the impact of conformity in medical education is warranted.

Practice analysis of chiropractic radiology: identifying items for part I of the clinical competency examination.

OBJECTIVE: The purpose of this study was to describe the current scope of practice of chiropractic radiologists by identifying frequent tasks conducted as well as those conditions most often seen and those that present the greatest risk of harm to patients. METHODS: A mixed-methods approach was used. An online survey was conducted with 91 diplomates listed with the American Chiropractic Board of Radiology. Participants rated the frequency of tasks they perform and conditions they see on a 5-point scale from "never" to "daily." They also rated the level of risk each condition presents to patients on a 5-point scale from "no risk" to "severe risk." Frequency and risk ratings were then presented in rank order to 22 subject matter experts at 3 focus groups. RESULTS: The most frequent task reported was writing radiology reports (mean [SD], 4.29 [1.58]). Ratings of the frequency of conditions seen in practice and the risk they present to patients were ranked from the highest to lowest for frequency and risk separately. The most frequent conditions seen were reportedly those with structural or joint derangement; the highest risk conditions seen are those that are systemic. Focus group members recommended that some conditions receive higher rankings and that certain conditions be recategorized for future practice analyses. CONCLUSIONS: This study helps to define the current scope of practice of chiropractic radiologists and identify frequent tasks and conditions. These results inform the development of a new test outline for Part I of the chiropractic radiology certification examination to ensure that examinees are tested on the most important conditions chiropractic radiologists see in practice.

Ego identity development in physicians: a cross-cultural comparison using a mixed method approach.

BACKGROUND: The purpose of this study was to examine the career decision-making process of International Medical Graduates (IMGs). There are two main types of IMGs who apply for licensure in Canada. Canadian International Medical Graduates (CIMGs) were Canadian citizens before leaving to study medicine in a foreign country, in comparison to those non-CIMGs who had studied medicine in a foreign country before immigrating to Canada. Given that their motivations for becoming a doctor in Canada may differ, it is important to examine how they decided to become a doctor for each group separately. METHODS: A total of 46 IMGs participated in a semi-structured interview - 20 were CIMGs and 26 were non-CIMGs. RESULTS: An iterative process of content analysis was conducted to categorize responses from five open-ended questions according to the Ego Identity Statuses theory of career decision-making. Event contingency analysis identified a significant difference between CIMGs and non-CIMGs, Fisher's exact test (1) = 18.79, p < .0001. A total of 55% of CIMGs were categorized as identity achieved and 45% as foreclosed; 100% of non-CIMGs were classified as identity foreclosed. CONCLUSION: About half of the Canadian citizens who had studied medicine in a foreign country had explored different careers before making a commitment to medicine, and half had not. No IMGs, however, who studied medicine in another country before immigrating to Canada, had explored various career opportunities before selecting medicine.

A review of student evaluation of teaching: applications to veterinary medical education.

Student evaluation of teaching is ubiquitous to teaching in colleges and universities around the world. Since the implementation of student evaluations in the 1970s in the US, considerable research has been devoted to their appropriate use as a means of judging the effectiveness of teaching. The present article aims to (1) examine the evidence for the reliability, validity, and utility of student ratings; (2) provide seven guidelines for ways to identify effective instruction, given that the purpose of student evaluation is to assess effective teaching; and (3) conclude with recommendations for the integration of student ratings into the continuous evaluation of veterinary medical education.