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

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

Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition.

Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.

Near-peers effectively teach clinical documentation skills to early medical students.

BACKGROUND: Composing the History of Present Illness (HPI), a key component of medical communication, requires critical thinking. Small group learning strategies have demonstrated superior effectiveness at developing critical thinking skills. Finding sufficient faculty facilitators for small groups remains a major gap in implementing these sessions. We hypothesized that "near-peer" teachers could effectively teach HPI documentation skills and fill the gap of small group facilitators. Here, we present a head-to-head comparison of near-peer and faculty teaching outcomes. METHODS: Second-year medical students in a single institution participated in an HPI Workshop as a clinical skills course requirement. Students were randomly assigned a near-peer or faculty facilitator for the workshop. We compared mean facilitator evaluation scores and performance assessments of students assigned to either type of facilitator. RESULTS: Three hundred sixty-five students, 29 residents (near-peers) and 16 faculty participated. On post-session evaluations (5-point Likert scale), students ranked near-peer facilitators higher than faculty facilitators on encouraging participation and achieving the goals of the session (residents 4.9, faculty 4.8), demonstrating small, statistically significant differences between groups. Mean scores on written assessments after the workshop did not differ between the groups (29.3/30 for a written H&P and 9/10 for an HPI exam question). CONCLUSIONS: Near-peer facilitators were as effective as faculty facilitators for the HPI Workshop. Utilizing near-peers to teach HPI documentation skills provided teaching experiences for residents and increased the pool of available facilitators.

An Interprofessional Standardized Patient Case for Improving Collaboration, Shared Accountability, and Respect in Team-Based Family Discussions.

Introduction: The science of patient safety demonstrates that good communication is essential for effective interprofessional collaboration. Methods: We created a low-stakes, formative assessment with which medical students, pharmacy students, and nursing students could practice several of the Interprofessional Education Collaborative competencies. We aimed to enable students to practice collaborative care, respect for other disciplines, and shared accountability. Senior students from medicine, nursing, and pharmacy worked in teams to disclose a medical error to a standardized patient. The activity began with an icebreaker exercise wherein students learned about each other. Next, each team planned a strategy for error disclosure and collaboratively disclosed the error. Standardized patients evaluated the team's performance. Subsequently, students regrouped for a debriefing. The participating institutions administered a survey to their students. Results: In total, 1,151 students participated: 464 fourth-year students from the University of Houston College of Pharmacy, 450 third- and fourth-year students from Baylor College of Medicine, and 237 fourth-year students from Texas Woman's University Nelda C. Stark College of Nursing, all in Houston, Texas. Postsession survey data showed that students thought they achieved the relevant competencies. Students' understanding of the perspectives of the other two disciplines improved. Students found the simulation encounter and debriefing effective in helping them consider the contributions of other disciplines to patient care. Discussion: This interprofessional standardized patient activity enabled collaborative problem solving. The debriefing discussion broadened students' understanding of the expertise of the other disciplines and promoted shared accountability. Students found this activity engaging and effective.

Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis.

Objective: Mobile applications for improving diagnostic decision making often lack clinical evaluation. We evaluated if a mobile application improves generalist physicians' appropriate laboratory test ordering and diagnosis decisions and assessed if physicians perceive it as useful for learning. Methods: In an experimental, vignette study, physicians diagnosed 8 patient vignettes with normal prothrombin times (PT) and abnormal partial thromboplastin times (PTT). Physicians made test ordering and diagnosis decisions for 4 vignettes using each resource: a mobile app, PTT Advisor, developed by the Centers for Disease Control and Prevention (CDC)'s Clinical Laboratory Integration into Healthcare Collaborative (CLIHC); and usual clinical decision support. Then, physicians answered questions regarding their perceptions of the app's usefulness for diagnostic decision making and learning using a modified Kirkpatrick Training Evaluation Framework. Results: Data from 368 vignettes solved by 46 physicians at 7 US health care institutions show advantages for using PTT Advisor over usual clinical decision support on test ordering and diagnostic decision accuracy (82.6 vs 70.2% correct; P < .001), confidence in decisions (7.5 vs 6.3 out of 10; P < .001), and vignette completion time (3:02 vs 3:53 min.; P = .06). Physicians reported positive perceptions of the app's potential for improved clinical decision making, and recommended it be used to address broader diagnostic challenges. Conclusions: A mobile app, PTT Advisor, may contribute to better test ordering and diagnosis, serve as a learning tool for diagnostic evaluation of certain clinical disorders, and improve patient outcomes. Similar methods could be useful for evaluating apps aimed at improving testing and diagnosis for other conditions.

Interprofessional learning through shadowing: Insights and lessons learned.

BACKGROUND: Interprofessional education (IPE) aims to improve patient outcomes. Interprofessional shadowing improves students' knowledge of different roles and attitudes toward other professionals. AIM: This study evaluates (1) how pre-clinical medical students describe the roles of the healthcare professionals they shadowed, and (2) whether shadowing can be used to introduce medical students to the benefits of interprofessional collaboration, and if so, in what ways. METHODS: Second-year medical students shadow another discipline and write a reflection on the shadowed discipline (SD)'s role and collaboration in patient care. A non-proportional stratified random sample of these reflections was coded during an iterative process. Any number of the 13 possible codes could be assigned to each reflection. Codes relevant to the research questions underwent narrative analysis. RESULTS: The most frequent codes were "specific function of SD" (88%), "SD's general purpose" (86%), and "value of SD's role" (68%). One-third of reflections referenced "communication," and one-third mentioned "teamwork." Insights gained included an appreciation for interprofessional care and a global perspective on patient care, extending beyond the inpatient encounter. CONCLUSION: Through shadowing, students achieve several IPE core competencies and a broader perspective on patient care. Shadowing is an effective pedagogical method for IPE in the pre-clerkship curriculum.

Cheating in medical school: the unacknowledged ailment.

The reported prevalence of cheating among US medical students ranges from 0% to 58%. Cheating behaviors include copying from others, using unauthorized notes, sharing information about observed structured clinical encounters, and dishonesty about performing physical examinations on patients. Correlates of cheating in medical school include prior cheating behavior, burnout, and inadequate understanding about what constitutes cheating. Institutional responses include expulsion, reprimands, counseling, and peer review. Preventing cheating requires establishing standards for acceptable behavior, focusing on learning rather than assessment, involving medical students in peer review, and creating a culture of academic integrity. Cheating in medical school may have serious long-term consequences for future physicians. Institutions should develop environments that promote integrity.

Ischemic heart disease in women: a review for primary care physicians.

Ischemic heart disease (IHD) is the leading cause of death among women in the Western world, and its prevalence is growing. The pathophysiology of heart disease in women differs from that in men. Women with chest pain and abnormal stress tests are less likely than men to have critical stenosis of coronary arteries, a phenomenon attributed to endothelial dysfunction. Hypertension, intimal injury, and cholesterol are among the various factors that contribute to endothelial dysfunction. The presenting symptoms of IHD also differ in women. Women are more likely to describe neck and throat pain and to characterize the pain as intense, sharp, or burning. A history of coronary or other vascular disease, diabetes, or chronic kidney disease places patients at high risk for IHD. Risk factor modification can be tailored based on each patient's risk. Hormone replacement therapy, antioxidants, folic acid, and aspirin in healthy women under 65 years of age have recently been shown to be ineffective in the prevention of IHD.