Identifying and Exploring the Cognitive Nature of Threshold Concepts in Pharmacology to Improve Medical Students' Learning.

Phenomenon: Pharmacology is a fundamental healthcare discipline, but it can be difficult and counterintuitive for learners to learn. Navigation toward understanding pharmacology can be troublesome, but once the threshold to comprehension is crossed, learners can experience a transformative shift in their ways of thinking and practicing. We conducted an in-depth examination of threshold concepts within pharmacology, aiming to identify and prioritize their learning to improve the medical curriculum and enhance medical treatment and patient safety. Approach: We carried out a consensus generation process using the Nominal Group Technique (NGT) to identify potential threshold concepts in pharmacology. Participant groups of pharmacology experts and medical students considered, identified, reviewed, and ranked potential pharmacology threshold concepts within their own group. Then, using a logical, step-by-step approach, we combined the final ranked data from these multiple NGT sessions. We further analyzed these data using an abductive analysis approach; data were coded, categorized, reorganized, and conceptually mapped after critical evaluation. Conceptual themes were established corresponding to different phases of cognitive schema development. Findings: Six comprehensive conceptual themes were identified: Drug Mechanism of Action; Pharmacotherapeutics; Pharmacokinetics; Drug Receptor Interactions; Drug Terminology and Nomenclature; and Signaling Pathways. These concepts align with many of the key attributes of threshold concepts (e.g., troublesome, integrative and transformative). The cognitive schematic themes generated were (i) acquisition-troublesome; (ii) acquisition-transformative; (iii) automation-troublesome; (iv) automation-transformative. Insights: Transformative learning involves different stages of cognitive schema evolution, including acquisition, elaboration, and automation, and is influenced by both the inherent challenges of the concepts and limitations of human cognition. The high interactivity of these troublesome concepts challenge schema acquisition and automation. Troublesome concepts underpinning procedures or skills, while not easily explained by cognitive rules, can lead to slow, awkward, error-prone performance, creating additional barriers for practice. Integrating concepts into a coherent structure leads to the irreversible assimilation of knowledge and the transferability of both knowledge and skills, influencing learners' epistemological transitions and ontological transformations at theoretical and professional levels. Further work on designing instructional models around assisting and automating schemas around identified troublesome knowledge, while addressing the impact of cognitive load, has the potential to promote transformational learning.

Medical students' awareness of overdiagnosis and implications for preventing overdiagnosis.

Overdiagnosis is a growing health issue, yet our understanding of medical students' exposure to this concept within medical education is limited. Our aim was to explore students' experience of diagnostic learning to identify how overdiagnosis may be understood by students. During in-person and online semi-structured interviews throughout 2021, we explored the education experience of twelve Western Sydney University medical students in years 3-5. Through inductive thematic analysis we identified four themes. These themes encompassed student commitment to learning about diagnosis, lack of certainty surrounding diagnosis and emotional factors of medical care, overdiagnosis as seen through the lens of high and low-value care during clinical placements and student-identified missed learning opportunities related to overdiagnosis. This study found that medical students develop inherent knowledge of overdiagnosis through an interplay of personal factors, medical school curriculum and the setting in which their training takes place. Our findings allow insight for future improvement of medical curriculum to produce exceptional medical graduates.

Longitudinal exploration of students' identity formation during the transition from pre-clinical to clinical training using research poetry.

BACKGROUND: Transitions are critical periods that can lead to growth and, or, distress. Transitions are a sociocultural process, yet most approaches to transitions in practice and research do not explore the social or developmental aspects of entering a new training phase. Wenger reminds us that identity development is crucial when newcomers navigate change. In this paper, we use Wenger's modes of identification: engagement, imagination and alignment to explore students' identity development (as a student and professional) during the transition from pre-clinical to clinical training. METHODS: We enrolled nine 2nd-year medical students who generated 61 entries comprising audio diary (or typed) reflections over 9 months (starting 3 months before clinical clerkships began) and interviewed them twice. We used research poems (transcripts reframed as poetry) to help construct a meaningful, emotive elicitation of our longitudinal data and analysed data using sensitising concepts from Wenger's modes of identification. RESULTS: Students described their transition as a journey filled with positive and negative emotions and uncertainty about their current and future careers. Students navigated the transition using three mechanisms: (1) becoming more engaged through taking charge, (2) shaping their image of self through engagement and finding role models and (3) learning to flexibly adapt to clerkship norms by managing expectations and adopting a journey mindset. CONCLUSIONS: We successfully narrated students' identity formation during their transition to clinical training. We learned that students became more engaged over time by learning to take charge. They shaped their image of self by engaging in team activities and reflecting on role models. They learnt to adapt flexibly to clerkship norms by managing expectations and adopting a journey mindset. We suggest that institutions provide a safe opportunity for medical students to reflect, allowing students' transition periods to be lived, reflected on and supported.

The development and validation of a questionnaire to explore medical students' learning in a blended learning environment.

BACKGROUND: A blended learning environment is multifaceted and widely used in medical education. However, there is no validated instrument for exploring students' learning in a blended learning environment in medical programs. This study aimed to develop and validate an instrument for exploring how medical students learn in an undergraduate medical program that employs a blended learning approach. METHOD: Using Artino's seven step approach, we developed a questionnaire to investigate how medical students learn in a blended learning environment. For pilot testing, 120 students completed this 19-item questionnaire. These 19-items were evaluated for construct and convergent validity across an expert medical education panel. Further item testing was analysed with principal component analysis (PCA) with varimax rotation for item reduction and factor estimation. Hence, validity was thoroughly addressed to ensure the questionnaire was representative of the key focus questions. Cronbach's Alpha was used for item reliability testing, and Spearman's Rho was used for the correlation between the questionnaire items and the extensively used MSLQ. Hence, validity and reliability were systematically addressed. RESULTS: Exploratory Factor analysis identified four factors F1 and F3: Resources: Accessibility & Guidance (14-items), F2: Learning behaviours: Social and Contextual (5-items), and F4: Motivational factors: Intrinsic and Extrinsic Motivation (4-items). Internal consistency and reliability tests were satisfactory (Cronbach's Alpha ranged from 0.764 to 0.770). CONCLUSIONS: The resulting Blended Learning Questionnaire (BLQ) was determined to be a reliable instrument to explore undergraduate medical students' learning in a blended learning environment.

Students' social networks are diverse, dynamic and deliberate when transitioning to clinical training.

CONTEXT: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training. METHODS: Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T0 ) and then again four months later (T1 ). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed-methods analysis on this data. RESULTS: At T0 , eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1 . People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance). CONCLUSIONS: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions.

A patient expectations questionnaire for determining criteria for entrustment decisions.

INTRODUCTION: To train health professionals for patient-centered care, patient engagement in medical curriculum development and assessment is widely recommended. But there are few published methods on how to consult with patients effectively, particularly when creating entrustable professional activities (EPAs). In this mixed-method study, we developed a questionnaire for facilitating patient input when developing EPA assessment criteria. METHODS: We developed a questionnaire for documenting patient expectations of their doctors which included: patient interviews to identify questionnaire items, expert validation, cognitive interviews with respondents, and finally, pilot testing. For the pilot testing, 87 participants with a variety of health problems from medical/surgical wards and outpatient clinics at a tertiary hospital were recruited. The final questionnaire included open-ended and ranking-style questions. RESULTS: Using the questionnaire, patients could identify their key expectations of their doctors when managing their current medical problem. Most patients wrote clear, brief free-text responses directly applicable to EPA descriptors that were time-efficient to analyze. CONCLUSIONS: The questionnaire is a feasible method of recording patient expectations, enabling educators to consult with and include patient perspectives when developing criteria for entrustment decisions in a diverse range of clinical contexts.

Appraising the use of smartphones and apps when conducting qualitative medical education research: AMEE Guide No. 130.

Smartphone use is rampant in everyday life and is increasing in: patient management, teaching and learning of medicine and health research. There is untapped potential to use smartphones as research tools in MER for a range of research approaches. Qualitative research is increasingly common in medical education research (MER). Smartphone use as a research tool has not been well explored in MER and this Guide will be useful to researchers considering integrating smartphones specifically in qualitative MER. First, we discuss the potential for smartphones in qualitative MER. Then, we discuss the opportunities and drawbacks for using smartphones in qualitative MER. We then provide three principles to consider when conducting smartphone MER: communication, ethics and reflection. Next we share ten lessons that emerged from the literature and our experiences. We end by looking to the future of smartphones in qualitative MER and hope this Guide provides evidence-based information to optimise smartphone use in qualitative MER. This Guide is important as there is an urgent need to redefine ethical boundaries to account for blurred lines between personal and professional use of smartphones.

Moral judgement development during medical student clinical training.

BACKGROUND: Whereas experience and cognitive maturity drives moral judgement development in most young adults, medical students show slowing, regression, or segmentation in moral development during their clinical years of training. The aim of this study was to explore the moral development of medical students during clinical training. METHODS: A cross-sectional sample of medical students from three clinical years of training were interviewed in groups or individually at an Australian medical school in 2018. Thematic analysis identified three themes which were then mapped against the stages and dimensions of Self-authorship Theory. RESULTS: Thirty five medical students from years 3-5 participated in 11 interviews and 6 focus groups. Students shared the impacts of their clinical experiences as they identified with their seniors and increasingly understood the clinical context. Their accounts revealed themes of early confusion followed by defensiveness characterised by desensitization and justification. As students approached graduation, some were planning how they would make moral choices in their future practice. These themes were mapped to the stages of self-authorship: External Formulas, Crossroads and Self-authorship. CONCLUSIONS: Medical students recognise, reconcile and understand moral decisions within clinical settings to successfully reach or approach self-authorship. Curriculum and support during clinical training should match and support this progress.

Beyond the struggles: a scoping review on the transition to undergraduate clinical training.

CONTEXT: The transition to clinical training within medical school is often seen as a struggle and students remain in distress despite numerous efforts to minimise threats. Efforts to change this may be misdirected if they are based on narrow conceptualisations of transitions. The authors conducted a scoping review to explore existing conceptual perspectives regarding the transition within medical school from pre-clinical training to clinical training to suggest a research agenda and practical implications. METHODS: Between October 2017 and February 2018 the authors searched PubMed, MEDLINE, ERIC, PsycINFO, Web of Science and CINAHL for English language literature with no date limits and retrieved 1582 articles; 46 were included in this review. Two reviewers independently screened articles and extracted data. Data were then charted, analysed and discussed with the research team. RESULTS: The transition to clinical training was often described negatively as 'difficult', 'a problem' and 'a struggle'. Our analysis found that researchers in medical education conducted studies on the transition to clinical training from three conceptual perspectives: educational; social, and developmental. Most research approached the transition to clinical training as a problem to be addressed from an educational perspective through transition to clerkship courses and curriculum innovations. Some research was conducted from a social perspective, focusing on building relationships. Regarding development, authors found a few articles highlighting opportunities for personal and professional development by nurturing transferrable learning strategies and reflection. CONCLUSIONS: This review provides an empirical base on which future research can be built to better understand and support medical students' ability to navigate change. Finding new perspectives to approach the transition to clinical training could allow researchers to look beyond preparing students for struggles.

A qualitative exploration of transitions, compliance, and onboarding challenges for international students in health professional education degrees.

Background: Australia provides education services to international students which includes international students completing a health professional education (HPE) degree. Studying for a HPE degree can be challenging for most students. There are specific challenges for international students when completing a degree with clinical placements. The challenges international students can face include receiving adequate and timely information, understanding health service access, and receiving the correct information from education providers and agents.Objectives: To gain an in-depth understanding of the challenges for international health professional education students in accessing healthcare, understanding the requirements of compliance to attend clinical placements and the difficulties with attending clinical placements.Design: A semi-structured interview schedule based on findings from a survey (N = 318 participants) was used to explore international student perspectives in one-on-one interviews.Methods: Data were collected from international HPE students from a single Australian metropolitan multi-campus university using a questionnaire, which included qualitative open-ended questions, in addition to semi-structured follow-on interviews. Data collection took place between March and October 2021 and qualitative data were inductively thematically analysed.Results: Challenges reported in interviews by six international students were focused on understanding the navigation of new administrative systems and compliance processes. Students noted gaps in the communication of understanding legislative compliance requirements to attend clinical placements, difficulties accessing healthcare and making use of overseas student health cover, organisational issues, and transport issues when attending clinical placements.Conclusions: Higher education providers and international education agents must address communication deficits in course requirements linked to clinical placement prerequisites. This study highlights gaps in commencing international students' understanding, and higher education providers' communication of clear, timely detailed information.

Medical education and moral segmentation in medical students.

CONTEXT: Many studies indicate that increases in cognitive ability, maturity and educational experience lead to a general increase in moral reasoning skills. However, research has shown that moral development does not occur during medical school and that it may, in fact, plateau or even regress. There is no empirical evidence as to what might be the cause of such a result. OBJECTIVES: The present study aimed to assess moral judgement competence in medical students and to investigate trends in moral judgement competence in relation to age, gender, culture, religion, year of medical course and different programmes within the medical curriculum. METHODS: We employed a cross-sectional and descriptive design over two consecutive years (2011 and 2012). Students completed Lind's Moral Judgement Test (MJT), which is based on Kohlberg's stages of moral development and is used to measure moral judgement competence (C-INDEX). C-INDEX results were analysed in relation to age, gender, cultural background, religion, cohort and specific programmes within the medical curriculum. RESULTS: The numbers of students who completed the MJT in 2011 and 2012 were 394 and 486, respectively. The two studies showed a significant difference and negative correlations between the moral judgement competence of medical students and both age and year of medical course (p < 0.001). The findings suggested the existence of a phenomenon known as 'moral segmentation', which increased significantly as students progressed through medical education, and were significantly linear between cohorts. CONCLUSIONS: Students show a decline in moral judgement competence during medical education. This probably reflects an increase in moral segmentation rather than an inhibition in moral development. The challenge is to develop a curriculum that will enable medical students to maintain, or better, increase their moral judgement competence.

Maintaining empathy in medical school: it is possible.

BACKGROUND: Empathy is an indispensable skill in medicine and is an integral part of 'professionalism'. Yet, there is still increasing concern among medical educators and medical professionals regarding the decline in medical students' empathy during medical education. AIMS: This article aims at comparing the levels of empathy in medical school students across the different years of undergraduate medical education. It also aims at examining differences in empathy in relation to gender, year of study, cultural and religious backgrounds, previous tertiary education and certain programmes within the curriculum. METHOD: The Jefferson Scale of Physician Empathy, Student version (JSPE-S) was employed to measure empathy levels in medical students (years one to five) in a cross-sectional study. Attached to the scale was a survey containing questions on demographics, stage of medical education, previous education, and level of completion of particular programmes that aim at promoting personal and professional development (PPD). RESULTS: Four hundred and four students participated in the study. The scores of the JSPE-S ranged from 34 to 135 with a mean score of 109.07 ± 14.937. Female medical students had significantly higher empathy scores than male medical students (111 vs. 106, p < 0.001) across all five years of the medical course. There was no significant difference in the total empathy scores in relation to year of medical education. Yet, the highest means were scored by year five students who had completed personal and professional development courses. CONCLUSIONS: Our findings suggest that there is a gender difference in the levels of empathy, favouring female medical students. They also suggest that, despite prior evidence of a decline, empathy may be preserved in medical school by careful student selection and/or personal and professional development courses.

Twelve tips for adopting the virtual Nominal Group Technique (vNGT) in medical education research.

Nominal Group Technique (NGT) is a structured approach to consensus development and data collection driven by problem-solving, idea inception and prioritisation. Challenges of the coronavirus disease 2019 (COVID-19) pandemic necessitated the development of a virtual (vNGT) model to recruit participants from diverse locations and time zones. Our reflections reveal the opportunities and challenges of using Zoom © for NGT sessions, resulting in more effective engagement and focus with fewer distractions compared to in-person meetings. The 12 tips provide practical suggestions for expanding the versatility of NGT in a virtual environment. These recommendations cover every aspect of the process, including the person, place, and object, from planning the sessions, and utilising technology resources effectively, to ensuring a seamless implementation to desirable outcomes. The paper strives to assist individuals in effectively using the online NGT as a substitute for in-person events, promoting effective management of remote participants even during unprecedented times of quarantine and physical distancing.

Medical students' self-regulation of learning in a blended learning environment: a systematic scoping review.

BACKGROUND: Medical curricula are constantly evolving in response to the needs of society, accrediting bodies and developments in education and technology. The integration of blended learning modalities has challenged traditional methods of teaching, offering new prospects in the delivery of medical education. The purpose of this review is to explore how medical students adapt their learning behaviours in a Blended Learning environment to become more independent and self-regulated, in addition to highlighting potential avenues to enhance the curriculum and support student learning. METHODS: Using the approach described by Levac et al. (2010), which builds on Arksey and O'Malley's framework, we conducted a literature search of the following databases: MEDLINE (Ovid), ERIC, EBSCO, SCOPUS and Google Scholar, utilising key terms and variants of "medical student', 'self-regulated learning' and 'blended learning'. The search yielded 305 studies which were further charted and screened according to the Joanna Briggs Institute. RESULTS: Forty-four studies were identified and selected for inclusion in this review. After full analysis of these studies, underpinned by Self-regulation theory, five major concepts associated with students' learning behaviours in a Blended Learning environment were identified: Scaffolding of instructional guidance may support self-regulated learning; Self-regulated learning enhances academic performance; Self-regulated Learning improves study habits through resource selection; Blended learning drives student motivation and autonomy; and the Cognitive apprenticeship approach supports Self-regulated learning. CONCLUSION: This review uncovers medical students' learning behaviours within a Blended learning environment which is important to consider for curricular adaptations and student support.

Medical Students' Socialization Tactics When Entering a New Clinical Clerkship: A Mixed Methods Study of Proactivity.

PURPOSE: Socialization into clinical clerkships is difficult in part due to ambiguity around students' new roles and expected behaviors. Being proactive reduces ambiguity and is essential to socialization. Proactive behavior can be taught and goes beyond having a proactive personality. Among students entering new undergraduate clinical clerkships, this study aimed to investigate (1) reported proactive behaviors and their association with social integration and (2) enabling and inhibiting factors for proactive behavior. METHOD: This study was conducted at the 5-year MBBS program at Western Sydney University during academic year 2019-2020. Using a convergent mixed methods approach, survey and interview data from third-, fourth-, and fifth-year students were collected. Surveys explored 5 proactive behaviors: feedback seeking, information seeking, task negotiation, positive framing, and relationship building. Interviews elicited descriptions of how students described their proactivity and what influenced students to be proactive when entering a new clerkship. Data were integrated using the following the thread and mixed methods matrix techniques. RESULTS: Students exhibited all 5 proactive behaviors. Survey data showed positive framing and task negotiation had the highest and lowest scores, respectively. Only positive framing correlated significantly with social integration scores (r = 0.27; P < .01), but this contrasted to interviews, in which students described how other proactive behaviors also led to social integration. Proactive behavior scores decreased across academic years. Integrated data showed 3 linked antecedents to whether students exhibited proactive behavior: feeling capable of being proactive, individual intention to be proactive, and the immediate environment and system-level factors. CONCLUSIONS: Students who framed the experience positively were more likely to report increased social integration. Initiating task negotiation was challenging for most students. The authors propose a conceptual model for proactivity and social integration to support socialization and learning during clinical transitions for future research and interventional design.

Understanding Patient Expectations of Health Care: A Qualitative Study.

Understanding and measuring patient expectations of health care is central to improving patient satisfaction and delivering patient-centered care. However, most empiric research in this field has focused on measuring patient expectations for specific diseases only. Patient expectations common to a variety of settings and clinical contexts need to be better understood to design measures with wider utility. We aimed to understand how patients express and conceptualize their expectations of health care across a range of clinical contexts and conditions. Semi-structured interviews were conducted with patients presenting to a major metropolitan hospital, informed by interpretive phenomenological analysis. Sampling continued until thematic saturation. Interview topics explored the illness experience, interactions with clinicians, how patients communicated and conceptualized their expectations of health care, and the nature of these expectations. The 26 participants conceptualized and described their expectations in 3 distinct domains: (1) health outcomes, (2) individual clinicians, and (3) the health-care system. Importantly, these domains were consistent across a variety of clinical contexts, participant demographics, and medical conditions. Despite variation in expectations due to individual patient circumstances, we identified 3 conceptual domains within which expectations consistently lie. When designing measurement tools for patient expectations, we suggest incorporating questions specifically addressing the 3 domains we have identified. With such measures, clinicians and health-care providers can be empowered to provide and monitor patient-centered care with outcomes tailored to what patients desire.

Challenging the Hidden Curriculum through Problem Based Learning: A reflection on Curricular Design.

This article was migrated. The article was marked as recommended. Problem-Based Learning pedagogy has been around since the late 1960s. However, PBL case-writing still constitutes an arduous task with much debate about how the cases should be written. The influence of the different PBL-writing styles and approaches have upon medical students requires attention and research. The Western Sydney University medical school has recently undergone a PBL renewal project, redesigning and rewriting 52 high quality PBL cases. Much thought and consideration were exerted in the planning and delivery of this project with a focus not only on the deep-learning and understanding of the basic and clinical sciences, but also on the importance of patient-centeredness. In this paper, we emphasize how language used in PBL cases can have a profound impact on students through implicit learning and the hidden curriculum. We also recommend having a writer, experienced in the use of narrative and emotive language, in addition to clinicians and medical educators in the authorship of PBL cases.

Imagining alternative professional identities: reconfiguring professional boundaries between nursing students and medical students.

The transition of a medical student or a nursing student into a health care practitioner requires many changes. Among these is the development of an appropriate professional identity, which assists in the establishment of a sound base for professional practice and therefore should be a focus for health professions educators. There is evidence, however, that medical education and nursing education face challenges in guiding students' development of appropriate professional identities. In medicine, there is concern that medical education may contribute to the development of professional identities that alienate patients rather than identities that are patient centered. The nursing profession struggles with poor retention rates in the workforce, which have been attributed in part to discrepancies between the professional identities that students develop during nursing school and the realities of professional practice.In this Perspective, the authors explore the importance of and the pedagogical strategies used to facilitate professional identity formation for medical and nursing students. They argue that medical and nursing educators aim to instill in their students strong occupational identities which may perpetuate hierarchical disciplinary boundaries. They suggest that health professions educators should move beyond current disciplinary silos and create interprofessional education opportunities for medical students and nursing students to learn together to facilitate the development of the collaborative interprofessional identities necessary for the delivery of high-quality, patient-centered health care.