Under- and post-graduate training to manage the acutely unwell patient: a scoping review.

BACKGROUND: Junior doctors are often the first responders to acutely unwell patients and yet frequently report feeling under-prepared to do so. To understand whether this is consequential of how medical students and doctors are trained to manage acutely unwell patients, a scoping review was conducted using a systematic approach. METHODS: The review, informed by the Arksey and O'Malley and PRISMA-ScR guidelines, identified educational interventions targeting the management of acutely unwell adults. Seven major literature databases were searched for journal articles published in English from 2005 to 2022, in addition to the Association of Medical Education in Europe (AMEE) conference proceedings from 2014 to 2022. RESULTS: Seventy-three articles and abstracts were eligible for the review, the majority of which were from the UK or USA, and demonstrated that educational interventions were more commonly targeted at medical students than qualified doctors. The majority of studies used simulation, but very few integrated complexities of the clinical environment within scenarios such as multidisciplinary working, distraction-handling techniques and other non-technical skills. A wide range of learning objectives pertaining to acute patient management were stated across studies, but few explicitly cited educational theory underpinning their study. CONCLUSIONS: The results of this review encourages future educational initiatives to consider enhancing authenticity within simulation to promote transfer of learning to clinical practice, and use educational theory to augment the sharing of educational approaches within the community of clinical education practice. Additionally, increasing the focus on post-graduate learning, building upon undergraduate educational foundations, is essential to promoting lifelong learning within the ever-changing healthcare environment.

Twelve tips for facilitating medical students prescribing learning on clinical placement.

Prescribing is a complex clinical skill requiring mastery by the end of basic medical training. Prescribing errors are common in newly qualified doctors, aligned with expressed anxiety about prescribing, particularly with high-risk medications. Learning about prescribing needs to start early in medical training, underpinned by regular opportunities for reflective practice. Authentic learning within the clinical work environment is more effective than lecture based learning and allows potential immediate feedback. Educational strategies should support prescribing learning underpinned by appropriate formative and summative assessments. Students should routinely be expected to use resources including an online formulary, sustained through tracking individual progress through use of their own personal formulary or 'p' drugs. Regular prescribing practice with embedded feedback during undergraduate training will help to ensure newly qualified doctors are more confident and competent prescribers.

Pre-University education curriculum reform and the generic learning skills of medical school entrants: Lessons learned from South Africa.

Background: Pre-university education curriculum changes may increase the skills and knowledge gap between secondary (high school) and tertiary (university) education that have been identified as having a major impact on the success of students from underresourced educational backgrounds. This study investigated the impact of extensive pre-university curriculum revision on the generic learning skills of entrants to South African medical schools, which admit students directly from high school. Methods: In this prospective study, students entering four medical schools during 2008-2011 were surveyed to determine their practice of and confidence in information handling, managing own learning, technical and numeracy skills, and computer, organizational, and presentation skills in the 12-month preceding entry. The 2008 entrants were the final cohort of the old secondary school curriculum. The mean levels of practice or confidence of entrants to the four medical schools, during 2008-2011, were compared using analysis of variance. The Bonferroni's test was used for further pair-wise comparison of cohorts of students either entering in different years or different institutions. Results: While entrants at the four medical schools did not demonstrate a consistent or sustained change in their practice of or confidence in each skill category over the period of study, there were some significant differences between entrants at the respective institutions. Furthermore, entrants to one medical school were consistently less confident of their skills, despite more practice. These findings are best accounted for by the long-standing history of inequitably resourced pre-university education in South Africa. Discussion: These findings highlight the need for close monitoring of the impact of pre-university education changes on the learning skill profiles of university entrants, in order to design effective university programs which enable students from diverse backgrounds to participate and adequately meet curricula demands.

Appreciative inquiry in medical education.

The practice of medicine, and also medical education, typically adopts a problem-solving approach to identify "what is going wrong" with a situation. However, an alternative is Appreciative Inquiry (AI), which adopts a positive and strengths-based approach to identify "what is going well" with a situation. The AI approach can be used for the development and enhancement of the potential of both individuals and organizations. An essential aspect of the AI approach is the generative process, in which a new situation is envisioned and both individual and collective strengths are mobilized to make changes to achieve the valued future situation. The AI approach has been widely used in the world of business and general education, but is has an exciting potential for medical education, including curriculum development, faculty development, supporting learners through academic advising and mentoring, but also for enhancing the teaching and learning of both individuals and groups. This AMEE Guide describes the core principles of AI and their practical application in medical education.

Feedback mapping - The curricular cornerstone of an "educational alliance".

PURPOSE: The "educational alliance" concept articulates a collaborative framework to facilitate effective feedback through transparency of opportunities aligned with learner stage and intended educational outcomes. Using this framework, we evaluated feedback across a 5 year undergraduate medical program to support embedding a successful learner - teacher "educational alliance". METHOD: A comprehensive mapping exercise used an iterative action research process of source documentary analysis, consultations with key curriculum stakeholders and qualitative analysis. The "educational alliance" model provided a critical lens through which to ensure feedback opportunities aligned with intended learning outcomes and developmental progression. RESULTS: Key information about the type, frequency and timing of feedback opportunities was identified within 188 curricular components. The purpose and intended learning outcomes were mapped, aligning with the stage of learning and with an expectation of supporting learners' capacity for self-regulation. This focus providing clear articulation of feedback opportunities supported the longitudinal developmental curricular review, and facilitated enhanced awareness of dialogic feedback within the "educational alliance". CONCLUSIONS: Explicit alignment of learning intentions between learner and educator is key to forming a successful "educational alliance". The feedback map provides clarity ensuring mutual understanding of intended learning outcomes. The iterative process additionally certified feedback aligned with maturing learner developmental needs across the program.

What can medical educators learn from the Rio 2016 Olympic Games?

Medical Educators face an ongoing challenge in optimizing preparedness for practice for newly qualified doctors. Junior doctors have highlighted specific areas in which they do not feel adequately equipped to undertake their duties, including managing the acutely unwell patient. In these highly stressful, time-critical scenarios it might be assumed that a lack of knowledge underpins these feelings of apprehension from junior medics; however, having studied, trained and passed examinations to demonstrate such knowledge, perhaps other factors should be considered. The recent Olympic Games in Rio demonstrated the impact of sport psychology techniques in allowing athletes to achieve their optimum performance in the face of adversity. The use of mental and behavioral strategies to control feelings of anxiety and low self-efficacy are pivotal for athletes to deliver their best performance under extreme pressure. We consider whether such techniques could improve the preparedness of the newest recruits to the healthcare system, and the impact this could have on patient care. Finally, suggestions for potential research directions within this area are offered to stimulate interest amongst the research community.

The supervisor's toolkit: A framework for doctoral supervision in health professions education: AMEE Guide No. 104.

Doctoral studies represent a complex undertaking for students and supervisors. Some research describes the experience of students while there are volumes of advice for students considering a doctorate. Yet the terrain for supervisors is less well-trodden and the concept of a pedagogy of supervision is only really starting to emerge. Texts on the doctoral journey from the supervisor's perspective are uncommon and less yet has been written in the context of health professions education. The aim of this Guide, therefore, is to provide guidance for the supervisor's journey, drawing on our collective experience and such literature as there is. We explore the doctoral journey of students and their supervisors, highlighting what the implications are for supervisory practice. Recognising the doctorate as much more than merely conducting a research project, and seeing it as a shared educational endeavour is fundamental to understanding the doctoral journey - a journey that is complex and mutable, constantly shifting as the candidate moves from novice to expert, from dependence to growing autonomy. Our intention is to present this Guide as a toolkit for both the novice and the experienced supervisor as it, on the one hand, seeks to make the practice of supervision more transparent while on the other, challenges the reader to critically reflect on the supervisory space in which they currently reside. Our hope is that the Guide opens up opportunities for generative conversations about the practice of doctoral supervision in health professions education.

A model of professional self-identity formation in student doctors and dentists: a mixed method study.

BACKGROUND: Professional self-identity [PSI] can be defined as the degree to which an individual identifies with his or her professional group. Several authors have called for a better understanding of the processes by which healthcare students develop their professional identities, and suggested helpful theoretical frameworks borrowed from the social science and psychology literature. However to our knowledge, there has been little empirical work examining these processes in actual healthcare students, and we are aware of no data driven description of PSI development in healthcare students. Here, we report a data driven model of PSI formation in healthcare students. METHODS: We interviewed 17 student doctors and dentists who had indicated, on a tracking questionnaire, the most substantial changes in their PSI. We analysed their perceptions of the experiences that had influenced their PSI, to develop a descriptive model. Both the primary coder and the secondary coder considered the data without reference to the existing literature; i.e. we used a bottom up approach rather than a top down approach. RESULTS: The results indicate that two overlapping frames of reference affect PSI formation: the students' self-perception and their perception of the professional role. They are 'learning' both; neither is static. Underpinning those two learning processes, the following key mechanisms operated: [1] When students are allowed to participate in the professional role they learn by trying out their knowledge and skill in the real world and finding out to what extent they work, and by trying to visualise themselves in the role. [2] When others acknowledge students as quasi-professionals they experience transference and may respond with counter-transference by changing to meet expectations or fulfil a prototype. [3] Students may also dry-run their professional role (i.e., independent practice of professional activities) in a safe setting when invited. CONCLUSIONS: Students' experiences, and their perceptions of those experiences, can be evaluated through a simple model that describes and organises the influences and mechanisms affecting PSI. This empirical model is discussed in the light of prevalent frameworks from the social science and psychology literature.

Electives in undergraduate medical education: AMEE Guide No. 88.

This Guide outlines the scope and potential roles an elective can contribute to undergraduate medical training and identifies ways to maximize learning opportunities, including within global health. The types of educational activity available for electives range from meeting individual educational need through to exploration of potential career pathways, with many factors influencing choice. Key areas of organization underpinning a successful elective before, during and after the placement include developing clarity of the intended educational outcomes as well as addressing practicalities such as travel and accommodation. Risk management including the implications for the participating schools as well as the student and their elective supervisors is crucial. This Guide would not be complete without some discussion around ethics and professional conduct during an elective, with consideration of the impact of elective placements, particularly in low-middle income countries.

How do undergraduate medical students perceive social accountability?

AIM: The concept of social accountability within undergraduate training is embedded within the remit of medical schools. Little is known of how medical students perceive social accountability, recognize aspects of their training contributing to the development of this concept and cultivate the underpinning values. METHODS: Students nearing graduation were recruited to participate in focus groups designed to explore their perceptions of social accountability, which curricular aspects had contributed to their understanding, and to investigate the implications of individual variations in training. RESULTS: Students expressed limited appreciation of the concept of social accountability and acknowledged little explicit teaching around underpinning core concepts such as awareness of local health needs, advocacy and nurturing of altruism. However, participants recognized numerous aspects of the course and learning initiatives as impacting on their attitudes towards this concept implicitly. CONCLUSION: This study highlights areas of their undergraduate training that students recognize as having the greatest impact on their development into socially accountable professionals. It poses some significant challenges for health care educators in addressing unintended consequences, including an outcome-driven educational approach, in reducing students' capacity or willingness to engage in curricular challenges often designed to embed this concept.

Generic learning skills in academically-at-risk medical students: a development programme bridges the gap.

BACKGROUND: Widening access to medical students from diverse educational backgrounds is a global educational mandate. The impact, on students' generic learning skills profiles, of development programmes designed for students at risk of attrition is unknown. AIMS: This study investigated the impact of a 12-month Intervention Programme (IP) on the generic learning skills profile of academically-at-risk students who, after failing at the end of the first semester, completed the IP before entering the second semester of a conventional medical training programme. METHODS: This prospective study surveyed medical students admitted in 2009 and 2010, on entry and on completion of first year, on their reported practice and confidence in information handling, managing own learning, technical and numeracy, computer, organisational and presentation skills. RESULTS: Of 414 first year students, 80 (19%) entered the IP. Levels of practice and confidence for five of the six skills categories were significantly poorer at entry for IP students compared to conventional stream students. In four categories these differences were no longer statistically significant after students had completed the IP; 62 IP students (77.5%) progressed to second year. CONCLUSIONS: A 12-month development programme, the IP, effectively addressed generic learning skills deficiencies present in academically-at-risk students entering medical school.

Maturational differences in undergraduate medical students' perceptions about feedback.

CONTEXT: Although medical students receive varied feedback throughout their training programmes, research demonstrates that they frequently perceive it as insufficient. However, supervisors tend to perceive that it is adequate. Students' responses to, and use of, feedback are not clearly understood. The purposes of this study were to investigate how medical students recognise, respond to and utilise feedback, and to determine whether there are maturational differences in understandings of the role of feedback across academic years in medical school. METHODS: This was a mixed-methods study collecting qualitative (focus group and open-ended questionnaire items) and quantitative (questionnaire) data across the 5 years of an undergraduate programme. RESULTS: A total of 68 students participated in 10 focus groups. The questionnaire response rate was 46% (564/1233). Data analysis investigated the students' perceptions of feedback and explored patterns of responses across the continuum of undergraduate medical school stages. Maturational differences among the year cohorts within the programme emerged in three general areas: (i) student perceptions of the purpose of feedback; (ii) student recognition of feedback, and (iii) student perceptions regarding the credibility of feedback providers. CONCLUSIONS: Junior students generally perceived the receiving of feedback as a passive activity and preferred positive feedback that confirmed their progress and provided reassurance. More senior students viewed feedback as informing their specific learning needs and personal development. They valued immediate informal verbal feedback and feedback from peers and others, as well as that from senior teachers. Exploring students' progressive degrees of engagement with feedback and its relationship with self-esteem are subjects for further study.

Generic skills in medical education: developing the tools for successful lifelong learning.

CONTEXT: Higher education has invested in defining the role of generic skills in developing effective, adaptable graduates fit for a changing workplace. Research confirms that the development of generic skills that underpin effectiveness and adaptability in graduates is highly context-dependent and is shaped by the discipline within which these skills are conceptualised, valued and taught. This places the responsibility for generic skills enhancement clearly within the remit of global medical education. IMPLICATIONS: Many factors will influence the skill set with which students begin their medical training and experience at entry needs to be taken into account. Learning and teaching environments enhance effective skill development through active learning, teaching for understanding, feedback, and teacher-student and student-student interaction. Medical curricula need to provide students with opportunities to practise and develop their generic skills in a range of discipline-specific contexts. Curricular design should include explicit and integrated generic skills objectives against which students' progress can be monitored. Assessment and feedback serve as valuable reinforcements of the professed importance of generic skills to both learner and teacher, and will encourage students to self-evaluate and take responsibility for their own skill development. The continual need for students to modify their practice in response to changes in their environment and the requirements of their roles will help students to develop the ability to transfer these skills at transition points in their training and future careers. CONCLUSIONS: If they are to take their place in an ever-changing profession, medical students need to be competent in the skills that underpin lifelong learning. Only then will the doctors of the future be well placed to adapt to changes in knowledge, update their practice in line with the changing evidence base, and continue to contribute effectively as societal needs change.

The contribution and challenges of electives in the development of social accountability in medical students.

Overseas electives are a key feature of western medical schools, with a high proportion of senior students taking the opportunity to travel to poorly resourced countries. Development of enhanced clinical skills is the focus of most electives; however, they provide a valuable opportunity to enhance medical students' sense of social accountability. Medical schools have a responsibility to ensure adequate preparation by the students, including close liaison and negotiation with host institutions to ensure maximal benefit for both student and the host communities. Anticipating intended and unintentional learning outcomes, which relate not only to global health knowledge and clinical skills but incorporate explicit expectations of a range of generic, professional and social responsibility outcomes, will help to ensure maximum benefit. Incorporating reflective accounts and host feedback into elective assessments will contribute to students' development, and ensure viability and sustainability of this valuable learning opportunity.

Transferable skills of incoming medical students and their development over the first academic year: The United Arab Emirates experience.

Increasingly, it is being recognised in higher and medical education that learners should be adequately prepared for the unpredictable nature of professional practice. Several generic or transferable skills or capabilities (e.g., communication, information handling) that will enable graduates to function in an ever-changing professional world have been identified. Using a validated inventory comprising six categories of transferable skills, three cohorts of incoming male and female medical students at a Gulf university documented their level of practice and confidence for 31 skills. The exercise was repeated a year later. New medical students identified computer and organisational skills and the ability to manage their learning as strengths, but scores for technical and numeracy, information handling and presentation and communication skills suggested that learners generally required guidance. A year later, despite considerable self-reported information handling and communication skills development, learners generally did not consider themselves self-sufficient. A significant gender difference emerged, with incoming males reporting less experience and confidence in many skills. This gap was reduced but did not disappear over the first academic year. An audit such as this may be useful for identifying individual skills levels as well as providing insight into shortcomings in the academic programme in terms of opportunities for transferable skills development.

Using Insights From Sports Psychology to Improve Recently Qualified Doctors' Self-Efficacy While Managing Acutely Unwell Patients.

PROBLEM: Doctors experience a range of negative reactions when managing acutely unwell patients. These may manifest as emotions or behaviors. Without appropriate coping strategies, these emotions and behaviors can impede optimal clinical performance, which directly affects patient care. Athletes use performance enhancing routines (PERs) to minimize the effect of their negative emotions and behaviors on competitive performance. The authors investigated whether PERs could similarly improve recently qualified doctors' emotional and behavioral control while managing acutely unwell patients and whether the doctors perceived any effect on clinical performance. APPROACH: Twelve doctors within 2 years of graduation from medical school recruited from 2 sites in Sheffield and Chesterfield, United Kingdom, implemented PERs using the PERFORM (Performance Enhancing Routines For Optimization of Readiness using Metacognition) model over a 4-month period between April and December 2017. The doctors' perceptions of PERFORM's effect on their ability to manage patients was evaluated using self-reported mixed-methods data, including think-aloud commentaries, semistructured interviews, and self-efficacy scores. OUTCOMES: Doctors reported that PERFORM improved their ability to control negative emotions or behaviors during an acutely unwell patient in situ simulation, showing a statistically significant improvement in self-efficacy scores (P = .003, effect size = 0.89). Qualitative data revealed perceived improvement in aspects of clinical performance such as enhanced knowledge recall and decision making. These performance attributes appeared to positively impact interprofessional relationships and patient care. Doctors individualized their PERs and supported the wider implementation of PERFORM in health care education. NEXT STEPS: This is the first study to employ individualized PERs based on sports psychology in a medical context. The PERFORM model could be introduced into existing acute patient management courses to provide emotional regulation coaching alongside clinical skills training. Further research might investigate PERFORM's effect in other environments where emotional and behavioral control is paramount, such as surgery.

What do medical students understand by research and research skills? Identifying research opportunities within undergraduate projects.

BACKGROUND: Undergraduate research exposure leads to increased recruitment into academic medicine, enhanced employability and improved postgraduate research productivity. Uptake of undergraduate research opportunities is reported to be disappointing, and little is known about how students perceive research. AIM: To investigate opportunities for undergraduate participation in research, recognition of such opportunities, and associated skills development. METHOD: A mixed method approach, incorporating student focus and study groups, and documentary analysis at five UK medical schools. RESULTS: Undergraduates recognised the benefits of acquiring research skills, but identified practical difficulties and disadvantages of participating. Analysis of 905 projects in four main research skill areas - (1) research methods; (2) information gathering; (3) critical analysis and review; (4) data processing - indicated 52% of projects provided opportunities for students to develop one or more skills, only 13% offered development in all areas. In 17%, project descriptions provided insufficient information to determine opportunities. Supplied with information from a representative sample of projects (n = 80), there was little consensus in identifying skills among students or between students and researchers. Consensus improved dramatically following guidance on how to identify skills. CONCLUSIONS: Undergraduates recognise the benefits of research experience but need a realistic understanding of the research process. Opportunities for research skill development may not be obvious. Undergraduates require training to recognise the skills required for research and enhanced transparency in potential project outcomes.

Changing approach to undergraduate studies documented during annual appraisal of medical students.

BACKGROUND: Transition from school to university life involves maturation changes in areas of academic and personal life. METHOD: Evaluation of factors involved was studied though analysis of appraisal interview outcomes during the first two years, which documented achievements and goal setting in 511 medical students (98% of two student-year cohorts). Qualitative analysis identified key issues in study skills, aspects of personal lives and differences in approach to university life. RESULTS: Study goals were identified in 71% of first-year students. New study skills goals were set by over one-third of students in year 2, including goals for change in both learning techniques and assessment preparation. Organizational skills deficiencies were identified in 24.5% of first years, and as a new issue in an additional 16% of second years. Personal difficulties had little impact on resolution of study skills goals, whilst imbalances in study-leisure activities and organizational skills were significant. Motivation and consideration of career choice remained unresolved in 4.5% of second-year students. Some 63% of second years reported changes in approach to studies following discussion during the previous year's appraisal. CONCLUSION: Appraisals are resource intensive but valued highly by students. Appraisal outcomes provided valuable information elucidating factors affecting transition into university life.