Empowerment of Learners through Curriculum Co-Creation: Practical Implications of a Radical Educational Theory.

Framing the Issue: Medical education programs in the U.S. rely on the aphorism that faculty own the curriculum; that is, the specialized knowledge, skills, and attitudes of a physician are the province of the faculty to be delivered to tuition-paying students. From this view, the learner's role is one of passivity and deference. A contrasting approach, termed curriculum co-creation, frames education as a bi-lateral partnership. Co-creation results from learners, in collaboration with instructors, taking an active role in creating the goals and processes of an educational program. Such a partnership requires substantial revision of the expectations for both learners and instructors. In this Observations article, the idea of co-creation is applied to medical education and an aspirational vision for the role and value of faculty-student co-creation is advocated. Description and Explication: Co-creation partnerships of faculty and students occur in many forms, varying in degree of departure from traditional educational practice. Co-creation principles and partnerships can be deployed for almost all aspects of training including selection and organization of content, effective methods of instruction, and assessment of student learning. The outcomes of co-creation occur at three levels. The most specific outcome of co-creation is characterized by increased student engagement and enhanced learning. Broader outcomes include improved efficacy and value in the educational program and institution while, at the farthest-reaching level, a co-creative process can modify the medical profession itself. Although some specific instructional techniques to promote student involvement and input have historically been deployed in medical education, there is little evidence that students have ever been permitted to share in ownership. Implications for Medical Education: When fully embraced, curricular co-creation will be recognizable through improved student engagement and learning along with a revised understanding of how faculty-student relationships can foment reform in medical education and the culture of the profession. Further scholarship and research will be indispensable to examine how co-creative partnerships can flatten hierarchies within medical education and inspire the medical profession to be more inclusive and effective. Following the model of co-creation is expected to inspire learners by empowering them to participate fully as co-owners of their own education and prepare them to lead medical education in a different direction for the future.

Culture transformation by stealth: Leveraging incremental change to revamp the curriculum.

INTRODUCTION: Reshaping an existing education program from traditional structures and processes into competency-based medical education (CBME) is formidable. Emory University School of Medicine applied organizational change theory to introduce CBME into an established MD program by employing 'sustainable innovation', which introduces change incrementally. METHODS: Implementation of CBME began with the identification of core institutional values. Using the sustainable innovation approach, the first change was adoption of new program outcomes and student performance expectations. There were few changes that occurred to the structure of required courses and clerkships. This intentional approach allowed stakeholders to familiarize themselves with CBME prior to full implementation. RESULTS: Existing assessment processes remained intact while the faculty was trained for innovative assessment uses. For example, the assessment process was augmented by tagging all exam items using a controlled taxonomy and students' performance was linked longitudinally. Using sustainable innovation allowed time for data collection and evaluation throughout the implementation of CBME. DISCUSSION: Representing student achievement according to competencies, rather than as letter grades, is perceived as revolutionary by many stakeholders. Employing sustainable, incremental innovation facilitated stakeholder buy-in to the underlying principles of CBME. Fostering a new organizational culture will be the 'rate-limiting factor' for full implementation of CBME.

Outcomes, accreditation, interprofessional education, and the Tower of Babel.

Effective education necessitates a shared mental model of what and how learners should be taught. Students in various healthcare professions education programs learn together most effectively when programs have a shared mental model for education. Because healthcare professions education programs must satisfy their respective accreditation standards, the terminology of those standards reflects that body's shared mental model for education. Thus, interprofessional education (IPE) would be facilitated by common educational lexicon across accrediting bodies. In this study, the terminology used in the accreditation standards from several healthcare professions educational programs was measured. An analysis was conducted to illustrate whether terms used by accreditors were internally consistent and whether there was consistency across professions. Counts of learning outcomes terms used revealed little internal consistency within each set of standards. Additionally, the terms in the various standards documents used to describe educational outcomes were not consistent across accreditors. Individual healthcare professions educational programs find IPE difficult to implement and maintain for pre-professional students. This study suggests that these programs' learning outcomes, which are regulated by accreditation standards, probably conflict with implementation of IPE initiatives. Strategies to normalize learning outcomes language and develop shared mental models for IPE are needed.

Would Socrates Have Actually Used the "Socratic Method" for Clinical Teaching?

Medical students and residents are familiar with clinical teaching methods in which a faculty member poses a series of questions to them. This technique is often called the "Socratic method," but it is frequently perceived by learners as an attempt to demean them, a practice that is colloquially known as "pimping." The distinction between Socratic teaching and pimping lies in the perception of "psychological safety." Psychological safety allows learners to answer questions or ask for help without threats to their dignity or worthiness. In a psychologically safe clinical teaching context, learners recognize that questions posed by attending physicians probe their current understanding and guide them to expand their knowledge. In pimping, questions are posed to embarrass the learner and to reinforce the teacher's position of power over them. Absent a threat of disparagement or condemnation, learners are able to focus on building schema for knowledge, skills, and attitudes, rather than worrying about shielding their self-worth. This article presents the proper Socratic method, as intended by Socrates, and contrasts it with pimping. This perspective defines psychological safety as the pivotal factor distinguishing Socratic teaching from pimping, and establishes the foundation for empirical studies of these common practices in medical education.

A typology of teaching roles and relationships for medical education.

BACKGROUND: Educational programs involve interactions between the instructors and the learners. In these interactions, instructors may play various roles. However, a nomenclature for relationships with learners appropriate to those roles has not been developed for medical education. AIMS: This article presents a typology of instructor's roles to facilitate the connection of outcomes with instructional methods and to inform training sessions for instructors. METHOD: Published articles in general education and medical education were searched for examples of terms used for instructor's roles in developmental interactions. Examples were grouped and classified to develop a two-dimensional typology. RESULTS: The typology has eight categories on two dimensions. One dimension is the purpose for interaction: (1) knowledge transmission, (2) professional identity formation, (3) negotiating the institutional milieu, and (4) relationship building. The other dimension is dichotomous on whether the instructor is a member of the profession to which the learners aspire. Twelve terms were categorized: Advisor, Advocate, Buddy, Coach, Counselor, Facilitator, Guru, Master, Mentor, Role model, Teacher and Tutor. CONCLUSIONS: Faculty instructors in medical education are often pressed for time, so clarifying role expectations is a low-cost scheme to enhance results. Using the typology can align instructor behavior with the desired learner outcomes and enhance efficient use of instructional time.

Using a Scoring Rubric to Assess the Writing of Bioethics Students.

Educators in bioethics have struggled to find valid and reliable assessments that transcend the "reproduction of knowledge" to target more important skill sets. This manuscript reports on the process of developing and grading a minimal-competence comprehensive examination in a bioethics master's degree program. We describe educational theory and practice for the creation and deployment of scoring rubrics for high-stakes performance assessments that reduce scoring inconsistencies. The rubric development process can also benefit the program by building consensus among stakeholders regarding program goals and student outcomes. We describe the Structure of the Observed Learning Outcome taxonomy as a mechanism for rubric design and provide an example of how we applied that taxonomy to define pass/fail cut scores. Details about domains of assessment and writing descriptors of performance are also presented. Despite the laborious work required to create a scoring rubric, we found the effort to be worthwhile for our program.

A Case Study of Curriculum Co-creation During a Seminar-Style Course for Senior Medical Students.

Introduction: Opportunities to learn about education theory underpinning medical education are limited in both undergraduate and graduate medical education and predominantly focus on "student as teacher." Key components of education theory relevant to medical education, including learning theory, curricular design, and assessment design, are rarely included in student-as-teacher training. Opportunities for medical students to co-create curricula with faculty are scarce. Methods: We present the case study of a month-long, seminar-style course titled, Applications and Foundations of Education in Medical Education. We describe the course, report student feedback, and identify the value of curriculum co-creation expressed in student reflections. The course was designed by a faculty member with formal medical education training; students co-created their own learning outcomes through self-selected articles and personal reflections on the topics: How do people learn; what is the best way to teach; what is a curriculum; and how should students be assessed? Results: Forty-seven post-clinical students completed the course; 28 completed course evaluations. They strongly agreed that the class met its stated goals (4.89/5) and that faculty teaching (4.93/5) and supervision (4.93/5) were appropriate. Themes from student reflections expressed that the co-creation process was insightful about the profession itself, from the perspective of their own participation in learning how to become a member of the profession. Discussion: This course offered a unique opportunity for medical students to learn medical education beyond the skill of teaching. The course allowed deep immersion into current literature and offered the chance to plan and execute one's own learning.

A multinational perspective on "lifestyle" and other perceptions of contemporary medical students about general surgery.

OBJECTIVE: The aim of this multinational study was to measure and describe the perceptions of medical students toward general surgery as a career choice with a particular emphasis on "lifestyle." BACKGROUND: Past studies from individual countries have considered the perceptions of medical students toward general surgery. No multinational study to compare the perceptions of medical students from different geographic and socioeconomic regions toward general surgery, has been broadly disseminated. METHODS: A survey about student perceptions of a general surgery career was distributed to 9 medical schools in 8 countries. Two-way analysis of variance was performed on the basis of country, level of economic development [Human Development Index (HDI)], and sex. RESULTS: A total of 841 respondents were included in the study with a response rate of 60%. The overall rate of interest toward general surgery as a career choice was 24%. We noted differences in the reasons behind why medical students choose general surgery between very high HDI countries and medium/high HDI countries. In contrast, the most important reason for not choosing general surgery was found to be due to perceptions of an unpleasant lifestyle. The negative influence of "lifestyle" persisted across all countries, both sexes, and all levels of socioeconomic development. CONCLUSIONS: The negative influence of lifestyle is the most important reason why contemporary medical students from different parts of the world choose not to pursue general surgery. Strategies to counteract the perceived unfriendly nature of the lifestyle are essential to increase the interest of contemporary medical students toward general surgery.

Use of Cognitive Load Theory to Deploy Instructional Technology for Undergraduate Medical Education: a Scoping Review.

Although new instructional technologies have been widely adopted, cognitive load theory (CLT) is rarely used to inform deployment of those technologies. This scoping review of published literature examined CLT use in the design of teaching technologies for medical students. Three databases were queried, and thematic characteristics were extracted. Fourteen articles met the inclusion criteria. Themes extracted were: Subjects that are inherently visual were contexts for innovations, more than half of the interventions used the CLT modality principle, and CLT-based interventions had mostly positive outcomes. CLT is advantageous for medical education, but its full scope is rarely applied. A broader range of subject areas may benefit from CLT-based teaching.

Relationship of participation in an optional student-run clinic to medical school grades.

BACKGROUND: Medical school is arduous and participating in optional service-learning activities may compete with the required curriculum. The student-run SHARING Clinics at the University of Nebraska are managed by a Board of students who commit to extensive voluntary participation. PURPOSE: The purpose of this study was to determine whether optional service-learning participation resulted in compromised medical school grades. METHODS: Of 908 students who matriculated between 1999 and 2006, 87 served on the SHARING Board. A 2×2 repeated measures ANOVA was used to compare the grade point averages of Board members and non-members before and after participating on the Board. RESULTS: The grades for SHARING Board members and non-members were not statistically different. The study had sufficient statistical power to detect even a small effect size. CONCLUSIONS: Concern about compromised academic performance appears to be an invalid reason to avoid service-learning participation. The benefits of participation appear to outweigh the costs.

A comparison of student performance between two instructional delivery methods for a healthcare ethics course.

Healthcare ethics has become part of the standard curriculum of students in the health professions. The goals of healthcare ethics education are to give students the skills they need to identify, assess, and address ethical issues in clinical practice and to develop virtuous practitioners. Incorporating the medical humanities into medical school, for example, is intended to foster empathy and professionalism among students and to provide mechanisms for enhanced physician well-being. Yet, despite the long-standing inclusion of the humanities in nursing curricula, increases in the amount and kinds of scientific knowledge essential for clinical practice has resulted in the erosion of the "humanistic arts" from nursing education. One potential solution to this challenge comes with the increase in interprofessional education, where students in a variety of healthcare professions programs come together to learn about issues common to all healthcare fields.

A Scoping Review of Research into the Origins of Cynicism Among Medical Trainees.

There is a perception that medical trainees begin their training idealistic and full of excitement. Yet, there is growing recognition in scholarly literature that this idealism is replaced by cynicism as a result of the training process itself. The ultimate goal of this study was to review the current literature on cynicism during medical training in order to identify factors that engendered its development. Equipped with this information, medical education can expand data collection regarding cynicism in order to further inform the development of solutions to combat it. This scoping review was conducted with a broad search for published articles across three medical education databases using search terms "cynicism in medical students." Additional relevant articles were added from reference lists of included articles. Articles on cynicism in practicing professionals were excluded as were articles that focused on burnout. The search identified 161 unique articles; 30 articles merited full reading and 19 ultimately met inclusion criteria. Emergent themes comprised three categories: causes of cynicism, variations of cynicism among populations, and outcomes of cynicism. Within these 3 categories, 9 sub-categories were also extracted. From Kopelman's perspective (Kopelman in JAMA 250(15):2006-10, [11]), the presence of cynicism verifies that students' ideals are still alive because they recognize that things could be better and are disappointed that they are not; cynicism may be preferable to despair. This review revealed that trainees have not suffered a death of their ideals, but a burial. Corrective action may be able to excavate what was lost-an idealistic approach to medical training.

SBAR-LA: SBAR Brief Assessment Rubric for Learner Assessment.

Introduction: Structured communication tools are associated with improvement in information transfer and lead to improved patient safety. Situation, Background, Assessment, Recommendation (SBAR) is one such tool. Because there is a paucity of instruments to measure SBAR effectiveness, we developed and validated an assessment tool for use with prepractice health professions students. Methods: We developed the SBAR Brief Assessment Rubric for Learner Assessment (SBAR-LA) by starting with a preliminary list of items based on the SBAR framework. During an interprofessional team training event, students were trained in the use of SBAR. Subsequently, they were assigned to perform a simulated communication scenario demonstrating use of SBAR principles. We used 10 videos from these scenarios to refine the items and scales over two rounds. Finally, we applied the instrument on another subset of 10 students to conduct rater calibration and measure interrater reliability. Results: We used a total of 20 out of 225 videos of student performance to create the 10-item instrument. Interrater reliability was .672, and for eight items, the Fleiss' kappa was considered good or fair. Discussion: We developed a scoring rubric for teaching SBAR communication that met criteria for validity and demonstrated adequate interrater reliability. Our development process provided evidence of validity for the content, construct, and response process used. Additional evidence from the use of SBAR-LA in settings where communication skills can be directly observed, such as simulation and clinical environments, may further enhance the instrument's accuracy. The SBAR-LA is a valid and reliable instrument to assess student performance.

Collaborative research in medical education: a discussion of theory and practice.

CONTEXT: Medical education researchers are inherently collaborators. This paper presents a discussion of theoretical frameworks, issues and challenges around collaborative research to prepare medical education researchers to enter into successful collaborations. It gives emphasis to the conceptual issues associated with collaborative research and applies these to medical education research. Although not a systematic literature review, the paper provides a rich discussion of issues which medical education researchers might consider when undertaking collaborative studies. METHODS: Building on the work of others, we have classified collaborative research in three dimensions according to: the number of administrative units represented; the number of academic fields present, and the manner in which knowledge is created. Although some literature on collaboration focuses on the more traditional positivist perspective and emphasises outcomes, other literature comes from the constructivist framework, in which research is not driven by hypotheses and the approaches emphasised, but by the interaction between investigator and subject. DISCUSSION: Collaborations are more effective when participants overtly clarify their motivations, values, definitions of appropriate data and accepted methodologies. These should be agreed upon prior to commencing a study. The way we currently educate researchers should be restructured if we want them to be able to undertake interdisciplinary research. Despite calls for researchers to be educated differently, most training programmes for developing researchers have demonstrated a limited, if not contrary, response to these calls. CONCLUSIONS: Collaborative research in medical education should be driven by the problem being investigated, by the new knowledge gained and by the interpersonal interactions that may be achieved. Success rests on recognising that many of the research problems we, as medical educators, address are fundamentally interdisciplinary in nature. This represents a transition to bridge the dichotomy often presented in medical education between theory building and addressing practical needs.

A Review of Continuous Quality Improvement Processes at Ten Medical Schools.

The Liaison Committee on Medical Education now expects all allopathic medical schools to develop and adhere to a documentable continuous quality improvement (CQI) process. Medical schools must consider how to establish a defensible process that monitors compliance with accreditation standards between site visits. The purpose of this descriptive study is to detail how ten schools in the Association of American Medical Colleges' (AAMC) Southern Group on Educational Affairs (SGEA) CQI Special Interest Group (SIG) are tackling practical issues of CQI development including establishing a CQI office, designating faculty and staff, charging a CQI committee, choosing software for data management, if schools are choosing formalized CQI models, and other considerations. The information presented is not meant to certify that any way is the correct way to manage CQI, but simply present some schools' models. Future research should include defining commonalities of CQI models as well as seeking differences. Furthermore, what are components of CQI models that may affect accreditation compliance negatively? Are there "worst practices" to avoid? What LCME elements are most commonly identified for CQI, and what are the successes and struggles for addressing those elements? What are identifiable challenges relating to use of standard spreadsheet software and engaging information technology for support? How can students be more engaged and involved in the CQI process? Finally, how do these major shifts to a formalized CQI process impact the educational experience?

Developing an online prematriculation orientation program and its relation to student performance in the first class taken in medical school.

BACKGROUND: In 2004 the University of Nebraska College of Medicine developed an online prematriculation program, Fast Start, to introduce students to the environment and expectations in medical school. PURPOSE: This quantitative study was conducted to determine whether using Fast Start correlated with performance in the gross anatomy course. METHODS: A hierarchical regression analysis was used to correlate grades in gross anatomy with a set of common prediction variables and a variable for use of Fast Start. RESULTS: The results showed that the predictive power of the full model, including the Fast Start variable, was slightly stronger than for the reduced model. A separate model verified the absence of an interaction between Fast Start use and prior academic ability. CONCLUSIONS: The online Fast Start program provided an efficient and effective method of delivering a prematriculation student orientation experience; its use was associated with marginally improved performance in a medical school course.

Creation and Implementation of a Taxonomy for Educational Activities: A Common Vocabulary to Guide Curriculum Mapping.

PROBLEM: Undergraduate medical education (UME) has trended toward outcomes-based education, unveiling new issues for UME program organization and leadership. Using a common language for categorizing and linking all program components is essential. The Emory Curriculum Alignment Taxonomy (ECAT) was designed as a common vocabulary for curriculum mapping in the outcomes-based environment of the Emory University School of Medicine. APPROACH: The ECAT, developed in 2016, uses a set of 291 controlled identifiers, or "tags," to describe every educational activity's content, instruction, assessment, and outcomes, and thereby to align teaching inputs with student outcomes. Tags were drawn from external frameworks or developed by local stakeholders. A key feature is the arrangement of tags into eight categories, with the aim of balancing specificity and parsimony. Tags from multiple categories can be combined using Boolean operators to search for specific topics across the curriculum. OUTCOMES: In 2016-2017, all educational activities were tagged, including classroom events, workplace learning, mentored research, and student assessments. Tagging was done by two assistant deans and course/clerkship directors, which reinforced the importance of aligning instruction with assessment and aligning both of these with student outcomes. NEXT STEPS: Using the ECAT tags has linked instruction with achievement of student outcomes, has shown the compromises between specificity and parsimony were workable, and has facilitated comprehensive program management and evaluation. As the ECAT tags can be modified, other programs could adapt this approach to suit their context. Next steps will include aggregating data into a centralized repository to support reporting and research.