Academic coaching: Insights from the medical student's perspective.

Purpose: With the growing recognition of the role of coaching in competency-based medical education, many medical education training programs are investing significant resources into developing coaching programs. However, there is a lack of rigorous research on academic coaching programs in medical education and recommended coaching practices are based on expert opinion without incorporating the student perspective. The aim of this study was to investigate factors that affect a students' perception of a successful coaching experience.Materials and method: This was a qualitative study performed in November 2018 at a medical school in the United States with a formal coaching program. Appreciative inquiry was the theoretical framework used to develop the question guide. The authors facilitated two focus groups and then used Colaizzi's phenomenological analysis approach to analyze the transcripts.Results: A total of 21 students participated in the focus groups. The analysis revealed four themes that describe students' perceptions of successful coaching experiences: coach attributes, relational skills, coaching skills, and utilization of coaching. Each of these themes had specific dimensions.Conclusions: The findings from this study illuminate the student stakeholder perspectives on successful coaching relationships, and should be considered when developing a coaching program and faculty development.

Using a Six-Domain Framework to Include Biopsychosocial Information in the Standard Medical History.

PROBLEM: The traditional approach to physicians' history taking is designed to facilitate diagnosis and treatment of biomedical conditions. However, in the 21st century, health is critically influenced by the interaction of biomedical conditions and nonbiomedical factors such as patient's ability to manage chronic disease and the social determinants of health. Interventions to expand routine history taking to include nonbiomedical factors have not been widely adopted, possibly due to the difficultly of incorporating long checklists into routine care and the inability to achieve consensus on the relevant behavioral or social determinants of health content applicable to all patients. INTERVENTION: In 2015-2016, we introduced medical students to a 6-domain (biomedical and psychiatric conditions, behavioral health, living environment/resources, social support, and functional status) approach to history taking and instructed them to elicit information from each domain alongside the traditional approach. Students were required to obtain information from each domain in one admitting history or one daily progress note, discuss their findings with the attending physician, and involve members of the medical team in addressing concerns and barriers in the care of that patient. Students' history notes were reviewed for completeness and compared to those from a student control group. Students also completed a 10-question evaluation of the model. CONTEXT: The intervention was conducted during a 1-month rotation on a hospitalist general medicine service from May 2015 through August 2016. OUTCOME: Patient history and daily progress notes were collected from 38 fourth-year intervention students and compared to 24 control students on the same service from the previous year. Compared to control students, intervention students provided more patient information (p ≤ .001) in all nonbiomedical domains except behavioral health. Intervention students reported that the 6-domain model helped them identify clinical information that could be addressed with existing resources and prompted involvement of social workers, pharmacists, and nurses in care planning. They also indicated the framework added clinically valuable information and enhanced team-based care. LESSONS LEARNED: A domain-based framework can be used by medical students to identify clinically relevant behavioral conditions and social determinants of health tailored to individual patients while avoiding long standardized checklists. Arguably, routine collection of behavioral and social determinants of health is a necessary first step in enhancing physicians' awareness and skills in working with health care teams to address nonbiomedical determinants of patients' health.

The influence of MCAT and GPA preadmission academic metrics on interview scores.

Medical school admissions interviews are used to assess applicants' nonacademic characteristics as advocated by the Association of American Medical Colleges' Advancing Holistic Review Initiative. The objective of this study is to determine whether academic metrics continue to significantly influence interviewers' scores in holistic processes by blinding interviewers to applicants' undergraduate grade point averages (uGPA) and Medical College Admission Test (MCAT). This study examines academic and demographic predictors of interview scores for two applicant cohorts at the University of Michigan Medical School. In 2012, interviewers were provided applicants' uGPA and MCAT scores; in 2013, these academic metrics were withheld from interviewers' files. Hierarchical regression analysis was conducted to examine the influence of academic and demographic variables on overall cohort interview scores. When interviewers were provided uGPA and MCAT scores, academic metrics explained more variation in interview scores (7.9%) than when interviewers were blinded to these metrics (4.1%). Further analysis showed a statistically significant interaction between cohort and uGPA, indicating that the association between uGPA and interview scores was significantly stronger for the 2012 unblinded cohort compared to the 2013 blinded cohort (ß = .573, P < .05). By contrast, MCAT scores had no interactive effects on interviewer scores. While MCAT scores accounted for some variation in interview scores for both cohorts, only access to uGPA significantly influenced interviewers' scores when looking at interaction effects. Withholding academic metrics from interviewers' files may promote assessment of nonacademic characteristics independently from academic metrics.

Value of Near-Peer Mentorship from Protégé and Mentor Perspectives: A Strategy to Increase Physician Workforce Diversity.

PURPOSE: Mentorship is a critical aspect of personal and professional development in academic medicine and helps to improve career satisfaction, productivity, and social networking. However, individuals from communities underrepresented in medicine (URiM) across the training continuum experience difficulty obtaining mentors, even prior to college. The value of near-peer mentorship is less well studied in medicine relative to other fields. The purpose of this mixed methods study is to explore the mentorship experiences of high school student protégés and their medical student mentors, as well as provide a description of the key features of the Doctors of Tomorrow (DOT) program. METHODS: From November 2014 to September 2015, the authors used focus groups and critical incident narratives with 9th grade high school students as well as focus groups and semi-structured interviews with medical students to examine mentor-protégé experiences in the Doctors of Tomorrow (DOT) program. In 2016, thirty-one medical student mentors were asked to complete an online survey about their mentor experiences. Focus group and interview data were audio-recorded and transcribed verbatim. All data were coded using thematic analysis and recurring codes were organized into categories, then compared, scrutinized and arranged into broader themes by all authors. RESULTS: The analysis of data from 70 medical students and 52 high school students revealed that mentors and protégés valued their mentor relationships based on regular in-person and electronic contact, shared common non-academic interests, and the anticipated prolonged nature of the relationship. Mentors also reported they initiated contact with their protégés every 2-3 weeks and monthly outside of program events, with email communication as the most common modality. CONCLUSIONS: Near-peer relationships between high school and medical students may be an innovative strategy to promote health care careers, increase access to mentorship and develop meaningful mentorship relationships for URiM high school students.

Medical school handoff education improves postgraduate trainee performance and confidence.

OBJECTIVES: Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training. METHODS: About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05. RESULTS: About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05). CONCLUSIONS: This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

Using artistic-narrative to stimulate reflection on physician bias.

BACKGROUND: Physician bias toward patients directly impacts patient care and health outcomes. However, too little research has been done investigating avenues to bring about self-awareness in this area to eliminate commonly held stereotypes that fuel physician bias. PURPOSES: The purpose of this study was to explore the ways in which 2nd-year medical students' reflected on an artistic-narrative presentation given by a woman with sickle cell disease. METHODS: A total of 320 2nd-year medical student essays were reviewed for content relevant to the artistic-narrative presentation. A total of 75 essays were identified and served as the data for this study. These 75 essays were analyzed using qualitative interpretive thematic content analysis to identify students' perceptions and reflections on culture in the healthcare environment and the patient-provider relationship. RESULTS: The analysis of the reflective essays revealed that this exercise helped students acknowledge physician bias in pain treatment, foster empathetic views toward patients as individuals, and recognize various ways in which biased beliefs can provide incite in healthcare disparities. CONCLUSIONS: These findings suggest that the combination of methods--art, narrative, and written reflection--helped students acknowledge their own bias as well as the ways in which taken-for-granted assumptions and biases can influence patient care.

Trainees' perceptions of patient safety practices: recounting failures of supervision.

BACKGROUND: Ensuring that trainees receive appropriate clinical supervision is one proven method for improving patient safety outcomes. Yet, supervision is difficult to monitor, even more so during advanced levels of training. The manner in which trainees' perceived failures of supervision influenced patient safety practices across disciplines and various levels of training was investigated. METHODS: A brief, open-ended questionnaire, administered to 334 newly hired interns, residents, and fellows, asked for descriptions of situations in which they witnessed a failure of supervision and their corresponding response. RESULTS: Of the 265 trainees completing the survey, 73 (27.5%) indicated having witnessed a failure of supervision. The analysis of these responses revealed three types of supervision failures-monitoring, guidance, and feedback. The necessity of adequate supervision and its accompanying consequences were also highlighted in the participants responses. CONCLUSIONS: The findings of this study identify two primary sources of failures of supervision: supervisors' failure to respond to trainees' seeking of guidance or clinical support and trainees' failure to seek such support. The findings suggest that the learning environment's influence was sufficient to cause trainees to value their appearance to superiors more than safe patient care, suggesting that trainees' feelings may supersede patients' needs and jeopardize optimal treatment. The literature on the impact of disruptive behavior on patient care may also improve understanding of how intimidating and abusive behavior stifles effective communication and trainees' ability to provide optimal patient care. Improved supervision and communication within the medical hierarchy should not only create more productive learning environments but also improve patient safety.

A validated search assessment tool: assessing practice-based learning and improvement in a residency program.

OBJECTIVE: The objective of this study was to validate an assessment instrument for MEDLINE search strategies at an academic medical center. METHOD: Two approaches were used to investigate if the search assessment tool could capture performance differences in search strategy construction. First, data from an evaluation of MEDLINE searches from a pediatric resident's longitudinal assessment were investigated. Second, a cross-section of search strategies from residents in one incoming class was compared with strategies of residents graduating a year later. MEDLINE search strategies formulated by faculty who had been identified as having search expertise were used as a gold standard comparison. Participants were presented with a clinical scenario and asked to identify the search question and conduct a MEDLINE search. Two librarians rated the blinded search strategies. RESULTS: Search strategy scores were significantly higher for residents who received training than the comparison group with no training. There was no significant difference in search strategy scores between senior residents who received training and faculty experts. CONCLUSION: The results provide evidence for the validity of the instrument to evaluate MEDLINE search strategies. This assessment tool can measure improvements in information-seeking skills and provide data to fulfill Accreditation Council for Graduate Medical Education competencies.

A strategy for improving health disparities education in medicine.

INTRODUCTION: A health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population. DESCRIPTION: The Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation. EVALUATION: All five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the "Best Precourse Award". This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times. CONCLUSION: Ultimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.

First-year medical students' perceptions of physicians' responsibilities toward the underserved: an analysis of reflective essays.

OBJECTIVE: To explore medical students' perceptions of their future role as physicians as it relates to personal and professional responsibilities toward the underserved. METHODS: The authors conducted a qualitative content analysis of 53 first-year medical students' reflective essays focusing on the question: "Access to health care is a societal problem. Do physicians have a professional obligation to help by participating in free clinics, or otherwise doing some service-type activity? What are your personal feelings about how you might balance service to other people with personal issues like income, family, and career choice?" RESULTS: The student essays revealed students' awareness of the distinct expertise that enables physicians to offset limited access to health care. Although the majority of respondents supported physicians' responsibility to provide uncompensated care, a minority believed that there was no such responsibility attached to being a physician. Students also recognized the competing demands physicians often encounter that conflict with personal desires for service. CONCLUSION: The use of reflective essays in medical school curricula seems promising, in that they elicited students' beliefs on a complex topic with direct implications for professional identity and career decisions.

Coming of age with sickle cell disease and the role of patient as teacher.

OBJECTIVE: Patients with chronic conditions are encouraged to optimize their health care experience by educating themselves regarding their condition and care. This study sought to explore the ways in which adolescents and young adults with sickle cell disease (SCD) educate others about their condition and the meanings they give to their experiences with health care professionals. METHODS: Seventeen individuals with SCD participated in in-depth interviews regarding their experiences as an individual with SCD seeking health care. RESULTS: Our analysis revealed participants' belief in the ignorance concerning SCD by others, including health care professionals. Additionally, the participants suggested significant consequences of such a lack of knowledge and the strategies they used to overcome this barrier--primarily the development of the identity of patient-as-teacher. CONCLUSION: Sickle cell patients in general and adolescent sickle cell patients in particular are often underestimated and discounted as they relate the details of their pain. This study demonstrates that these participants are not only keepers of knowledge but also must work to educate authority figures and peers in their lives to ensure they are properly cared for and that those around them understand their disease.

Considerations for using race and ethnicity as quantitative variables in medical education research.

Throughout history, race and ethnicity have been used as key descriptors to categorize and label individuals. The use of these concepts as variables can impact resources, policy, and perceptions in medical education. Despite the pervasive use of race and ethnicity as quantitative variables, it is unclear whether researchers use them in their proper context. In this Eye Opener, we present the following seven considerations with corresponding recommendations, for using race and ethnicity as variables in medical education research: 1) Ensure race and ethnicity variables are used to address questions directly related to these concepts. 2) Use race and ethnicity to represent social experiences, not biological facts, to explain the phenomenon under study. 3) Allow study participants to define their preferred racial and ethnic identity. 4) Collect complete and accurate race and ethnicity data that maximizes data richness and minimizes opportunities for researchers' assumptions about participants' identity. 5) Follow evidence-based practices to describe and collapse individual-level race and ethnicity data into broader categories. 6) Align statistical analyses with the study's conceptualization and operationalization of race and ethnicity. 7) Provide thorough interpretation of results beyond simple reporting of statistical significance. By following these recommendations, medical education researchers can avoid major pitfalls associated with the use of race and ethnicity and make informed decisions around some of the most challenging race and ethnicity topics in medical education.

Diabetes stories: use of patient narratives of diabetes to teach patient-centered care.

A critical component to instituting compassionate, patient-centered diabetes care is the training of health care providers. Our institution developed the Family Centered Experience (FCE), a comprehensive 2-year preclinical program based on longitudinal conversations with patients about living with chronic illness. The goal of the FCE is to explore the experience of illness from the patient's perspective and ultimately to incorporate this perspective in clinical practice. In this qualitative study, we wished to investigate the impact of "diabetes stories"--the stories of FCE volunteers with diabetes--on medical students' understanding of diabetes and its management. Individual interviews were conducted with medical students who had worked with a volunteer with diabetes to answer the questions: "in what ways was learning through these 'diabetes stories' different from that acquired through lectures and textbooks," and "how did these stories impact the students' understanding of diabetes and its care?" Thematic analysis of the transcribed interviews was performed using Grounded Theory. Several major themes emerged: There was more to diabetes than the "scientific" knowledge acquired through lectures; the stories challenged students' assumptions about having or working with people with diabetes and allowed students to see the world through the perspective of someone with diabetes, and the stories motivated students' development as physicians and influenced their general perspectives of doctoring and medicine. First-person narratives of living with diabetes allow for learning in affective, experiential, and cognitive dimensions, stimulate self reflection and perspective-taking, and enhance growth through the challenging of previous assumptions, beliefs, and perspectives. This type of learning is transformative and may result in a shift in students' perspectives towards more open, inclusive attitudes towards patient-centered diabetes care.

Veteran-centred content in medical education.

BACKGROUND: Veterans have unique experiences that warrant special consideration in health care. Unfortunately, training in veteran-centred care has not been a clear focus of medical education, and only a very small proportion of medical schools include military cultural competency in their curricula. METHODS: We conducted an 80-minute focus group with six US veterans. Open-ended questions were used to elicit their perceptions of the health care that they receive, and how it can be improved. The audio-recording was transcribed verbatim and coded for thematic content. A phenomenological analytic approach was used to analyse the 31-page transcript and arrive at the final themes. RESULTS: Former service members from various periods of conflict (e.g. World War II, Vietnam, Persian Gulf) offered key insights about how to improve veterans' health care experiences. Veterans suggested that consideration of their previous military service would improve care. They lamented that the lack of military consciousness is a barrier to care. Finally, they suggested that clinicians pay close attention to the transition from service member to civilian, as reintegration to civilian life is a critical life experience. Training in veteran-centred care has not been a clear focus of medical education DISCUSSION: Veteran-centred care ensures optimal health care through ease of access to services, and through positive patient-provider interactions. Being aware of military culture can help providers to contextualise veterans' experiences and beliefs about health care seeking and illness management, particularly for invisible wounds of war, including traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD).

Limited by our limitations.

Study limitations represent weaknesses within a research design that may influence outcomes and conclusions of the research. Researchers have an obligation to the academic community to present complete and honest limitations of a presented study. Too often, authors use generic descriptions to describe study limitations. Including redundant or irrelevant limitations is an ineffective use of the already limited word count. A meaningful presentation of study limitations should describe the potential limitation, explain the implication of the limitation, provide possible alternative approaches, and describe steps taken to mitigate the limitation. This includes placing research findings within their proper context to ensure readers do not overemphasize or minimize findings. A more complete presentation will enrich the readers' understanding of the study's limitations and support future investigation.

Developing Professionalism and Professional Identity Through Unproctored, Flexible Testing.

The medical education community has devoted a great deal of attention to the development of professionalism in trainees within the context of clinical training-particularly regarding trainees' handling of ethical dilemmas related to clinical care. The community, however, knows comparatively less about the development of professional behavior in medical students during the preclerkship years. In medical schools with flexible testing, students take quizzes or examinations in an unproctored setting at a time of their choosing-as long as it falls within a specified window of time. Unproctored, flexible testing offers students early opportunities to develop appropriate professional behavior. In this Perspective, the authors outline different flexible testing models from three institutions-University of Virginia School of Medicine, University of Michigan Medical School, and Icahn School of Medicine at Mount Sinai-all of which offer various levels of testing flexibility in relation to time and location. The authors' experiences with these models suggest that preclinical medical students' early development of professional behavior requires scaffolding by faculty and staff. Scaffolding involves setting clear, specific expectations for students (often through the form of an honor code), as well as active engagement and discussion with learners about the expectations and procedures for self-regulation in the academic environment.

Medical students' perspectives on a multicultural curriculum.

OBJECTIVE: The Liaison Committee on Medical Education requires medical schools to deliver curriculum that prepares graduates to care for a culturally diverse patient population. This study explores student perceptions of 1 multicultural curriculum and their preparedness for dealing with: racism, stereotypes, community partnership and disparities. METHODS: Focus groups were conducted with 22 preclinical and clinical students. Participants were asked semistructured and open-ended questions. Using a conceptual approach to thematic content analysis of transcripts, the data were reviewed by the study's authors for common themes. RESULTS: The authors identified the following: 1) Students asserted that topics of multiculturalism, disparities and racism should be incorporated both throughout the curriculum and in discrete packages; these topics would be most effective if highlighted during their clinical training. 2) Students preferred learning about topics such as racism and bias from "real" patients. 3) At times, written cases may be counterproductive by reinforcing stereotypes. 4) Finally, students note that without recurrent assessment, many students do not perceive topics on multicultural issues as vital to their education. CONCLUSIONS: Given these recurring themes, we have reviewed our assessment strategies for the multicultural curriculum and are implementing a longitudinal assessment of our multicultural curriculum. Our findings should inform our school and others as to the need for further faculty development and clerkship materials in the area of cultural competency.

Using a Modified A3 Lean Framework to Identify Ways to Increase Students' Reporting of Mistreatment Behaviors.

PROBLEM: The proportion of students who experience mistreatment is significantly higher than the proportion of students who report mistreatment. Identifying ways to improve students' reporting of these incidents is one strategy for increasing opportunities to achieve resolution and prevent future occurrences. APPROACH: The authors applied a modified A3 Lean framework to examine medical student reporting of mistreatment behaviors at the University of Michigan Medical School (UMMS) in 2013-2016. The A3 Lean framework is a stepwise approach that involves outlining the background to establish the context of the problem, describing the current condition, identifying the goal or desired outcome, analyzing causes of the problem, providing proposed countermeasures for improvement, and creating follow-up plans. The authors identified three reasons for the difference between students' experiences and reporting of mistreatment and developed five countermeasures/action plan items to address this difference. OUTCOMES: The proportion of students reporting mistreatment at UMMS increased 21.4% between 2013 and 2016. Compared with 2013, more students in 2016 indicated not reporting because the incident did not seem important enough or because they resolved the issue on their own. NEXT STEPS: The authors have enlisted the support of the health system's human resources department and presented the inaugural grand rounds on improving the learning environment in 2016. Among other things, they are also partnering with this team to add questions about student mistreatment and civility to the annual employee engagement survey distributed to all 20,000 employees.

Assessing Residents' Veteran-Centered Care Skills in the Clinical Setting.

BACKGROUND: Despite their placement in Veterans Health Administration centers nationwide, residents' training and assessment in veteran-centered care is variable and often insufficient. OBJECTIVE: We assessed residents' ability to recognize and address mental health issues that affect US military veterans. METHODS: Two unannounced standardized patient (SP) cases were used to assess internal medicine residents' veteran-centered care skills from September 2014 to March 2016. Residents were assessed on 7 domains: military history taking, communication skills, assessment skills, mental health screening, triage, and professionalism, using a 36-item checklist. After each encounter, residents completed a questionnaire to assess their ability to recognize knowledge deficits. Residents' mean scores were compared across training levels, between the 2 cases, and by SP gender. We conducted analysis of variance (ANOVA) tests to analyze mean performance differences across training levels and descriptive statistics to analyze self-assessment questionnaire results. RESULTS: Ninety-eight residents from 2 internal medicine programs completed the encounter and 53 completed the self-assessment questionnaire. Residents performed best on professionalism (0.92 ± 0.20, percentage of the maximal score) and triage (0.87 ± 0.17), and they scored lowest on posttraumatic stress disorder (0.52 ± 0.30) and military sexual trauma (0.33 ± 0.39). Few residents reported that they sought out training to enhance their knowledge and skills in the provision of services and support to military and veteran groups beyond their core curriculum. CONCLUSIONS: This study suggests that additional education and assessment in veteran-centered care may be needed, particularly in the areas of posttraumatic stress disorder and military sexual trauma.

Use of interactive theater for faculty development in multicultural medical education.

BACKGROUND: The development of critical consciousness, anchored in principles of social justice, is an essential component of medical education. AIM: In order to assist faculty instructors in facilitating small-group discussions on potentially contentious issues involving race, gender, sexual orientation, and socioeconomic class, a faculty development workshop was created. METHODS: The workshop used 'Forum Theater' techniques in which the audience was directly involved in determining the course of a simulated classroom discussion and conflict. We assessed the workshop's impact on the instructors' attitudes regarding facilitation of small-group discussions through two surveys: one to gauge immediate impressions, and another, 9-15 months later, to assess impact over time. RESULTS: Immediately after the workshop, participants reported that the topics covered in the sketch and in the discussion were highly relevant. In the follow-up survey, the instructors agreed that the workshop had raised their awareness of the classroom experiences of minorities and women and had offered strategies for addressing destructive classroom dynamics. 72% reported that the workshop led to changes in their behavior as facilitators. Differences in responses according to gender were observed. CONCLUSIONS: A workshop using interactive theater was effective in training faculty to facilitate small-group discussions about multicultural issues. This approach emphasizes and models the need to foster critical consciousness in medical education.