"What's Next in My Arc of Development?": An Exploratory Study of What Medical Students Need to Care for Patients of Different Backgrounds.

PHENOMENON: Medical schools must equip future physicians to provide equitable patient care. The best approach, however, is mainly dependent on a medical school's context. Graduating students from our institution have reported feeling ill-equipped to care for patients from "different backgrounds" on the Association of American Medical Colleges' Graduation Questionnaire. We explored how medical students interpret "different patient backgrounds" and what they need to feel prepared to care for diverse patients. APPROACH: We conducted an exploratory qualitative case study using focus groups with 11, Year 2 (MS2) and Year 4 (MS4) medical students at our institution. Focus groups were recorded, transcribed, and coded using thematic analysis. We used Bobbie Harro's cycles of socialization and liberation to understand how the entire medical school experience, not solely the curriculum, informs how medical students learn to interact with all patients. FINDINGS: We organized our findings into four major themes to characterize students' medical education experience when learning to care for patients of different backgrounds: (1) Understandings of different backgrounds (prior to medical school); (2) Admissions process; (3) Curricular socialization; and (4) Co-curricular (or environmental) socialization. We further divided themes 2, 3, and 4 into two subthemes when learning how to care for patients of different backgrounds: (a) the current state and (b) proposed changes. We anticipate that following the proposed changes will help students feel more prepared to care for patients of differing backgrounds. INSIGHTS: Our findings show that preparing medical students to care for diverse patient populations requires a multitude of intentional changes throughout medical students' education. Using Harro's cycles of socialization and liberation as an analytic lens, we identified multiple places throughout medical students' educational experience that are barriers to learning how to care for diverse populations. We propose changes within medical students' education that build upon each other to adequately prepare students to care for patients of diverse backgrounds. Each proposed change culminates into a systemic shift within an academic institution and requires an intentional commitment by administration, faculty, admissions, curriculum, and student affairs.

Twelve tips for strengthening global equity in health professions education publication.

Despite recent calls to engage in scholarship with attention to anti-racism, equity, and social justice at a global level in Health Professions Education (HPE), the field has made few significant advances in incorporating the views of the so-called "Other" in understanding the nature, origin, and scope of knowledge as well as the epistemic justification of knowledge production. Editors, authors, and reviewers must take responsibility for questioning existing systems and structures, specifically about how they diffuse the knowledge of a few and silence the knowledge of many. This article presents 12 recommendations proposed by The Global South Counterspace Authors Collective (GSCAC), a group of HPE professionals, representing countries in the Global South, to help the Global North enact practical changes to become more inclusive and engage in authentic and representative work in HPE publishing. This list is not all-encompassing but a first step to begin rectifying non-inclusive structures in our field.

Whiteness theory and the (in)visible hierarchy in medical education.

CONTEXT: The theory of whiteness in medical education has largely been ignored, yet its power continues to influence learners within our medical curricula and our patients and trainees within our health systems. Its influence is even more powerful given the fact that society maintains a 'possessive investment' in its presence. In combination, these (in)visible forces create environments that favour White individuals at the exclusion of all others, and as health professions educators and researchers, we have the responsibility to uncover how and why these influences continue to pervade medical education. PROPOSAL: To better understand how whiteness and the possessive investment in its presence create (in)visible hierarchies, we define and explore the origin of whiteness by examining whiteness studies and how we have come to have a possessive investment in its presence. Next, we provide ways in which whiteness can be studied in medical education so that it can be disruptive. CONCLUSION: We encourage health profession educators and researchers to collectively 'make strange' our current hierarchical system by not just recognising the privileges afforded to those who are White but also recognising how these privileges are invested in and maintained. As a community, we must develop and resist established power structures to transform the current hierarchy into a more equitable system that supports everyone, not just those who are White.

Asian Conscientization: Reflections on the Experiences of Asian Faculty in Academic Medicine.

ISSUE: Asians have experienced a rise in racialized hate crimes due to the anti-Asian rhetoric that has accompanied the COVID-19 pandemic. However, there has been little acknowledgement of anti-Asian discrimination within the medical education community. While anti-Asian hate is not new or unfamiliar to us, four authors of Asian descent, it has given us an opportunity to reflect on how we have been complicit in and resistant to the larger racial narratives that circulate in our communities. EVIDENCE: In this article, we provide a brief history of Asians in the Americas with a focus on anti-Asian hate. Next, while presenting stories from the perspective of Asian medical education researchers who were born/have settled in the U.S. and Canada, we take the opportunity to reflect on how our personal experiences have shaped our perceptions of ourselves, and the representations of Asians in the field of medicine. IMPLICATIONS: We hope to create awareness about how stereotypes of success tied to Asians can be used as a tool of oppression creating strife between Black communities, Asian communities, and other people of color. There is a need to develop critical consciousness to address the issues of equity in academia and in clinical practice.

Skin Color Representation in Teaching Photographs: One Institution's Approach to Addressing Visual Racism in Medical Education.

Problem: Visual racism refers to both the underrepresentation and inappropriate representation of darker skin types in medical education. By not teaching medical students and resident physicians to recognize common conditions in darker skin, it perpetuates biases that contribute to healthcare disparities for racial and ethnic minoritized groups. In this paper we describe our efforts to engage in institutional anti-racism work by addressing imbalances in representation of darker skin types in visual teaching images within our institution's curriculum. Intervention: We initially surveyed preclinical medical students regarding their perceptions of skin color representation in two courses. Researchers recorded the skin types of all teaching photographs in these courses in 2020. We then provided feedback and education to faculty, proposing that they increase brown and black skin color representation in educational content. During 2021, we reviewed the same courses and surveyed students again to ascertain the implementation and impact of our proposal. Context: We applied our intervention to two courses, Host & Defense (H&D) and Skin, Muscle, Bone, and Joint (SMBJ) since both courses utilize a large number of teaching images. Impact: From 2020 to 2021, both H&D and SMBJ significantly increased the proportion of visual teaching images that included darker skin types, with an increase from 28% to 42% in H&D and 20% to 30% in SMBJ. Significantly more students in the courses' 2021 iterations (73% in H&D, 93% in SMBJ) felt that lectures had appropriate representations of darker skin types when compared to students who took the course in 2020 (8% in H&D, 51% in SMBJ). Students in 2021 felt more confident in recognizing dermatological signs and symptoms in patients with darker skin than students in 2020. The majority of students in both 2020 and 2021 reported wanting to see a gradient of skin types for every dermatological condition discussed. Lessons learned: Our work suggests that addressing visual racism can be achieved partly by setting expectations for increased visual representation, collaborating across educational departments, and establishing clear metrics for assessing implementation. Future interventions will require a continual feedback loop of monitoring learning material, assessing faculty and student perception, refining resources, and recommending revisions to improve visual representation across the entire curriculum.

Sharpening Our Tools: Conducting Medical Education Research Using Critical Theory.

Issue: As medical education continues to grapple with issues of systemic racism and oppression within its institutions, educational researchers will undoubtedly turn to critical theory to help illuminate these issues. Critical theory refers both to a "school of thought" and a process of critique that reveals the dynamic forces impacting minoritized groups and individuals. Critical theory can be helpful when researchers want to examine or expose social structures for their asymmetrical power differentials, and subsequently act upon them to create change. Evidence: However, despite the repeated calls for more critical work in medical education, merely describing critical theory's school of thought has not forwarded researchers' engagement with these theories. Presently, critical analyses remain rare in medical education. One potential reason for the lack of critical analyses is that there is little guidance for how researchers might engage with their data and approach their findings. Implications: In this paper, we go beyond merely describing critical theory and demonstrate how critical theory can be used as an analytic approach to interrogate the experiences of minoritized individuals in medical education. Using three critical theories: critical race theory, feminist theory, and postcolonial theory, we provide an illustration of how researchers might approach their data using one of three critical theories. In doing so, we hope to assist researchers in better understanding the utility of critical analyses to illuminate sociohistorical forces at work within medical education.

'Whispers and shadows': A critical review of the professional identity literature with respect to minority physicians.

OBJECTIVES: Professional identity formation (PIF) is a growing area of research in medical education. However, it is unclear whether the present research base is suitable for understanding PIF in physicians considered to be under-represented in medicine (URM). This meta-ethnography examined the qualitative PIF literature from 2012 to 2019 to assess its capacity to shine light on the experiences of minoritised physicians. METHODS: Data were gathered using a search of six well-known medical education journals for the term 'professional identit*' in titles, keywords, abstracts and subheadings, delineated with the date range of 2012-2019. All non-relevant abstracts were removed and papers were then further reduced to those that focused only on learners' experiences. This left 67 articles in the final dataset, which were analysed using a collaborative approach among a team of researchers. The team members used their professional expertise as qualitative researchers and personal experiences as minoritised individuals to synthesise and interpret the PIF literature. RESULTS: Four conceptual categories were identified as impacting PIF: Individual versus Sociocultural Influences; the Formal versus the Hidden Curriculum; Institutional versus Societal Values; and Negotiation of Identity versus Dissonance in Identity. However, a major gap was identified; only one study explored experiences of PIF in URM physicians and there was an almost complete absence of critical stances used to study PIF. Combined, these findings suggest that PIF research is building on existing theories without questioning their validity with reference to minoritised physicians. CONCLUSIONS: From a post-colonial perspective, the fact that race and ethnicity have been largely absent, invisible or considered irrelevant within PIF research is problematic. A new line of inquiry is needed, one that uses alternative frameworks, such as critical theory, to account for the ways in which power and domination influence PIF for URM physicians in order to foreground how larger sociohistorical issues influence and shape the identities of minoritised physicians.

Discovering the Benefits of Group Peer Review of Submitted Manuscripts.

Problem: Traditionally, journal editors expect individuals to complete peer reviews of submitted manuscripts on their own. Recently, a number of editors of health sciences journals have begun to support, and even espouse, the practice of group peer review (GPR). With GPR, multiple individuals work together to complete the review with permission from the journal editor. Motivated by the idea that GPR could provide a meaningful service learning experience for participants in an interprofessional educational scholarship course, we conducted three such reviews and subsequently reflected on our experience and the lessons we learned. We frame our reflections using guiding principles from the domains of peer review, professional development, and educational scholarship. Intervention: The course director arranged for manuscripts to review with the editors of three health sciences journals. Each GPR occurred during a separate weekly session of the course. Each GPR was completed using a similar set of steps, which included (a) gaining familiarity with review criteria, (b) reading aloud and discussing the manuscript's abstract as a class, (c) reading and critiquing assigned sections as individuals and then small groups, (d) building consensus and sharing notes, (e) having the course director synthesize notes into a single review for submission to the journal. Context: The course on educational scholarship involved 15 faculty representing faculty from the University of Utah's School of Medicine, College of Nursing, College of Pharmacy, College of Health, and School of Dentistry. The course director led three GPR sessions mid-way through the yearlong course. Impact: Participants' reflections indicate that GPR (a) conformed to principles of effective peer review; (b) resulted in a meaningful service learning experience within a formal professional development program, deepening understanding of core concepts of educational scholarship; and (c) represented an authentic example of engaging in educational scholarship (i.e., designing and evaluating an intervention while drawing upon and contributing to a body of shared understanding within a community of practice). Lessons Learned: Our principles-based approach to completing GPR within a professional development course on educational scholarship can serve as a model for others to follow. A rigorous, meaningful group review can occur in 1 hour using a combination of group and individual activities focused on matching review criteria to the submitted manuscript. As a result, we continue to include GPR in future offerings of this interprofessional course on educational scholarship, and we continue to study ways to optimize its value as a service learning experience.

Application of statistical techniques to proportional loss data: Evaluating the predictive accuracy of physical vulnerability to hazardous hydro-meteorological events.

Knowledge about the cause of differential structural damages following the occurrence of hazardous hydro-meteorological events can inform more effective risk management and spatial planning solutions. While studies have been previously conducted to describe relationships between physical vulnerability and features about building properties, the immediate environment and event intensity proxies, several key challenges remain. In particular, observations, especially those associated with high magnitude events, and studies designed to evaluate a comprehensive range of predictive features are both limited. To build upon previous developments, we described a workflow to support the continued development and assessment of empirical, multivariate physical vulnerability functions based on predictive accuracy. Within this workflow, we evaluated several statistical approaches, namely generalized linear models and their more complex alternatives. A series of models were built 1) to explicitly consider the effects of dimension reduction, 2) to evaluate the inclusion of interaction effects between and among predictors, 3) to evaluate an ensemble prediction method for applications where data observations are sparse, 4) to describe how model results can inform about the relative importance of predictors to explain variance in expected damages and 5) to assess the predictive accuracy of the models based on prescribed metrics. The utility of the workflow was demonstrated on data with characteristics of what is commonly acquired in ex-post field assessments. The workflow and recommendations from this study aim to provide guidance to researchers and practitioners in the natural hazards community.

Perspectives From Students and Faculty on How Women Achieve Leadership Roles in Academic Medicine: An Exploratory Qualitative Study.

INTRODUCTION: The glass ceiling in academic medicine has resulted in lower pay and fewer career advancement opportunities for women. Creating change relies on preparing early-career women for positions of leadership, but most leadership programs focus on faculty, not trainees. The present exploratory qualitative study investigates how to prepare women medical students to be leaders in academic medicine. METHODS: Focus groups with medical students and faculty who identify as women were conducted at an academic medical center in the West. A total of 25 individuals (10 students and 15 faculty) participated. Recordings of focus groups were transcribed and coded using thematic analysis until saturation of themes was achieved. FINDINGS: Codes were organized into three themes: obstacles, support systems, and self-presentation. Obstacles identified included the subthemes microaggressions, macroaggressions, a lack of female role models in leadership, and personal characteristics such as the ability to self-promote and remain resilient. Support systems included sponsorship, allyship, mentorship, networking, and gender-specific role modeling subthemes. Self-presentation involved learning behaviors for demonstrating leadership and exuding confidence, being strategic about career moves, resiliency, and navigating social norms. CONCLUSIONS: The key themes of obstacles, support systems, and self-presentation are targets for systemic and individualistic improvement in leadership development.

Contribution of Basic Science Education to the Professional Identity Development of Medical Learners: A Critical Scoping Review.

PURPOSE: Professional identity development (PID) has become an important focus of medical education. To date, contributions of basic science education to physician PID have not been broadly explored. This review explores the literature surrounding the contribution of basic science education to the PID of medical learners and interprets findings critically in terms of the landscapes of practice (LoP) framework. METHOD: In this critical scoping review, the authors searched 12 different databases and professional organization websites from January 1988 to October 2022 for references relating to how, if at all, the basic science component of medical education contributes to the PID of medical learners. The LoP learning theory was chosen as a framework for critically interpreting the identified articles. RESULTS: Of the 6,674 identified references, 257 met the inclusion criteria. After data extraction, content analysis of recorded key findings was used to ensure all findings were incorporated into the synthesis. Findings aligned with and were critically interpreted in relation to the 3 LoP modes of identification: engagement (engaging in the work of a physician), imagination (imagining oneself becoming a "good doctor"), and alignment (aligning with the practices and expectations of a medical community or specialty). Within each mode of identification, it was possible to see how basic science may support, or catalyze, PID and how basic science may serve as a barrier, or an inhibitor, to PID or contribute to the development of negative aspects of identity development. CONCLUSIONS: The LoP learning theory suggests that the effect of basic science on physicians' PID is most effective if educators view themselves as guides through interfaces between their scientific disciplines and medicine. Learners need opportunities to be engaged, to imagine how their current learning activities and developing skills will be useful as future physicians, and to feel alignment with medical specialties.

Medical Student Experiential Learning in Telesimulation.

OBJECTIVES: Telesimulation utilizes telecommunication technology to engage learners in simulation while in different physical locations. Despite this potential advantage, understanding of the student experience and assessment of student learning in telesimulation activities is limited. This study evaluates medical student emotional experience and self-identified learning in telesimulation through the Kolb experiential learning framework and qualitative analysis. METHODS: Fourth-year medical students enrolled in the Spencer Fox Eccles School of Medicine at the University of Utah participated in 3 telesimulation activities as part of a required internal medicine course. Students were surveyed regarding their satisfaction with the activity (N = 114) and responded to questions about their emotional experience and self-identified areas of learning. Free-text responses were analyzed using qualitative content analysis to identify themes until thematic saturation (N = 66). RESULTS: Students were highly satisfied with telesimulation, with greater than 90% of students expressing a positive view of simulation realism, debrief quality, and group size. Themes of anxiety and uncertainty, confidence versus incompetence, team dynamics, fun, and difficult patient interaction were identified regarding the emotional experience. Themes of communication and teamwork, managing emotions, information gathering, differential diagnosis, resource reference, executing treatment, and medical knowledge were identified regarding student-identified learning. CONCLUSION: In this analysis of medical student experiences with telesimulation, we found students have rich emotional, cognitive, and behavioral experiences and self-identify learning across a variety of domains. Our findings support further study of telesimulation for medical student learning and demonstrate how assessment of outcomes via Kolb framework, using the learner's reflective observation and self-identified learning, may help better define learning outcomes from simulation.

Impact of Culinary Medicine Course on Confidence and Competence in Diet and Lifestyle Counseling, Interprofessional Communication, and Health Behaviors and Advocacy.

Most physicians report inadequate training to provide diet and lifestyle counseling to patients despite its importance to chronic disease prevention and management. To fill the nutrition training gap, elective Culinary Medicine (CM) courses have emerged as an alternative to curriculum reform. We evaluated the impact of an interprofessional CM course for medical and health professional students who experienced the hands-on cooking component in person or a in mixed-mode format (in-person and via Zoom) at the University of Utah from 2019-2023 (n = 84). A factorial ANOVA assessed differences between educational environment and changes between pre- and post-course survey responses related to diet and lifestyle counseling, interprofessional communication, and health behaviors and advocacy. Qualitative comments from post-course surveys were analyzed on a thematic level. Students rated themselves as having greater confidence and competence in diet and lifestyle counseling (p < 0.05) and increased ability to prepare eight healthy meals (p < 0.05). Additionally, a Mann-Whitney two-sample rank-sum test was used to compare data from exit survey responses from medical students who took the CM course (n = 48) and did not take the CM course (n = 297). Medical students who took CM were significantly more likely to agree that they could counsel patients about nutrition (p < 0.05) and physical activity (p < 0.05). CM courses may improve students' confidence to provide diet and lifestyle counseling.

"I really liked the chance to talk about it": Students' Reflections on the Process of Completing Paper Puzzles, a Novel Active Learning Activity.

Introduction: Research shows active learning is an effective teaching method. However, few qualitative studies explore medical student perceptions of the active learning process. The present study explored what students thought about while completing paper puzzles, an active learning tool used at the University of Utah School of Medicine, to understand what and how medical students think while engaged in active learning. Materials and Methods: To investigate second-year medical students' attitudes toward these active learning exercises, three Zoom-based focused groups were held and recorded throughout the course. Recordings were transcribed and coded using thematic analysis. Results: Students reported that peer interactions were of high value, and that while some interactions and thought processes were action-oriented, others were more metacognitive. Other benefits of the activity included promotion of learning, provision of structure, and designation of high-yield concepts. Challenges included feelings of confusion, problems with timing or difficulty of the tasks, and low utility without adequate preparation. Discussion: These findings reflect student-acknowledged pros and cons of active learning described in education literature and add further insight into the thoughts and conversations students have during active learning activities. These include practicing metacognitive skills, triaging information, and learning from peers. Conclusions: These data further elucidate student perceptions of active learning activities in medical education. Though focused on a specific activity, the data can help medical educators understand what students appreciate about active learning and what they think about while engaged in such activities. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01682-y.

Making the Personal Statement "Truly Personal": Recommendations From a Qualitative Case Study of Internal Medicine Program and Associate Program Directors.

Background: The personal statement is an integral part of a residency application but little guidance exists for medical students about what content to include. Objective: We use the framework of isomorphism, the process by which institutions model themselves after one another, to understand what internal medicine program directors (PDs) and associate program directors (APDs) recommend be included in the personal statement and how programs use personal statements in their selection of applicants to interview and rank. Methods: Semi-structured phone interviews were conducted between August and October 2020 with 13 academic PDs and APDs, who were selected for participation based on program size and geographic location. Interviews were recorded, transcribed, and coded using content analysis. Results: Effective personal statements should be well-written, present unique information, and demonstrate fit with a residency program. PDs and APDs recommended against expressing lack of interest in a program or highlighting negative personal characteristics. PDs and APDs used personal statements to distinguish between applicants and noted that personal statements help programs form an impression of the applicant. Consensus among PDs and APDs about what personal statements should include and how they are used indicates that isomorphism influences the match process. Conclusions: Our study found that the personal statement is a valued part of the residency application when it includes unique attributes and reveals personal values that align with that of the program. Additionally, PDs and APDs noted that when applicants highlight their unique characteristics, it can help distinguish themselves from others.

"Am I even a med-student anymore?" A Mixed-Methods Study of the Impact of the Initial Disruptions Caused by the COVID-19 Pandemic on Medical Student Professional Identity Formation.

Purpose: Developing a professional identity requires learners to integrate themselves into the medical profession and take on the role of doctor. The impact of COVID-19 on medical education has been widely investigated, but little attention has been paid to the impact of students' professional identify formation (PIF). The goal of this study was to investigate the impact that the onset of the COVID-19 pandemic had on medical students' PIF. Materials and Methods: An embedded mixed-methods design was utilized. Focus groups were conducted with a subset of year 1-4 students and coded using thematic analysis. Year 1-2 students were surveyed about their professional identity integration in the spring of 2020. Responses were analyzed using descriptive statistics and Wilcoxon signed rank and Mann-Whitney U tests. Results: Qualitative data were organized into six themes that touched on losses and challenges, reflection, and reevaluation of the physician career. Roughly 50% of MS1s and MS2s reported a change in their professional identity integration, but this was not statistically significant. Conclusions: Medical education does not occur in isolation and is influenced by disruptive local and global events. Students perceived challenges when in-person community interaction and hands-on clinical experiences were interrupted. Additionally, students reflected upon their own role and their future career goals. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01652-4.

Assessment for Learning with Ungraded and Graded Assessments.

Introduction: Assessment for learning has many benefits, but learners will still encounter high-stakes decisions about their performance throughout training. It is unknown if assessment for learning can be promoted with a combination model where scores from some assessments are factored into course grades and scores from other assessments are not used for course grading. Methods: At the University of Utah School of Medicine, year 1-2 medical students (MS) completed multiple-choice question quiz assessments and final examinations in six systems-based science courses. Quiz and final examination performance counted toward course grades for MS2017-MS2018. Starting with the MS2020 cohort, quizzes no longer counted toward course grades. Quiz, final examination, and Step 1 scores were compared between ungraded quiz and graded quiz cohorts with independent samples t-tests. Student and faculty feedback was collected. Results: Quiz performance was not different for the ungraded and graded cohorts (p = 0.173). Ungraded cohorts scored 4% higher on final examinations than graded cohorts (p ≤ 0.001, d = 0.88). Ungraded cohorts scored above the national average and 11 points higher on Step 1 compared to graded cohorts, who had scored below the national average (p ≤ 0.001, d = 0.64). During the study period, Step 1 scores increased by 2 points nationally. Student feedback was positive, and faculty felt it improved their relationship with students. Discussion: The change to ungraded quizzes did not negatively affect final examination or Step 1 performance, suggesting a combination of ungraded and graded assessments can effectively promote assessment for learning.

Instagram as a virtual art display for medical students.

Implication Statement We require our medical students to create art as part of a core course. Projects have historically been displayed at our health sciences library. During a rapid adjustment to virtual teaching at the onset of the COVID-19 pandemic, using Instagram to hold a virtual art show was a quickly implemented alternative. With student consent, course directors posted different artwork every weekday for eight weeks to a course account. By capitalizing on the visual strengths and extensive reach of the Instagram platform, we promoted our medical students' talents both locally and nationally. We plan to use Instagram and in-person displays in the future. Énoncé des implications de la recherche Dans un de leurs cours du tronc commun, nos étudiants en médecine sont amenés à faire de l'art. Avant la pandémie de la COVID-19, leurs projets étaient exposés à la bibliothèque des sciences de la santé. La solution de rechange trouvée dans le cadre d'une adaptation rapide à l'enseignement virtuel au début de la pandémie a été d'utiliser Instagram pour exposer virtuellement les œuvres. Avec le consentement des étudiants, les responsables de cours ont publié des œuvres différentes tous les jours pendant huit semaines sur un compte Instagram créé pour le cours. Tirant parti des atouts visuels et de la vaste portée de la plateforme, nous avons pu promouvoir les talents de nos étudiants en médecine tant au niveau local qu'au niveau national. À l'avenir, nous comptons combiner les expositions physiques et Instagram.

Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors.

OBJECTIVES: Clinical reasoning skills are essential for sound medical decision-making. Though many have suggested that clinical reasoning instruction should begin in pre-clerkship curricula, neither pre-clerkship clinical skills director perspectives nor extent of instruction is known. This survey study serves as part of a needs assessment for United States medical school pre-clerkship clinical reasoning curricula. METHODS: United States medical school pre-clerkship clinical skills course directors were surveyed about perceived importance of formal instruction on clinical reasoning concepts, inclusion of these concepts in the curricula, barriers to instruction, and familiarity with clerkship curricula. Results were analyzed using descriptive and analytic statistics. Narrative comments were analyzed qualitatively for themes. RESULTS: Of 148 directors surveyed, 102 (69%) participated and 89 (60%) completed all closed-ended items. Each clinical reasoning concept was identified as somewhat to extremely important to include in pre-clerkship curricula by 90-99% of respondents. Pre-clerkship curricula included variable degrees of formal instruction for concepts, though most respondents rated their inclusion as moderate or extensive. Perceived importance of teaching most concepts moderately correlated with the degree of inclusion in the curriculum (Spearman's rho 0.39-0.44). Curricular time constraints and lack of faculty with skills to teach these concepts were the most frequently cited barriers to instruction. Respondents indicated being somewhat 57% (n=54) to extremely 29% (n=27) familiar with clerkship curricula at their institutions. CONCLUSIONS: This study is the first to examine pre-clerkship clinical skills course director perspectives about clinical reasoning instruction and extent of its inclusion in their curricula.