The impact of informed self-assessment on the development of medical students' learning goals.

PURPOSE: This study investigates the contributions of self-assessment (SA) and external feedback on the development of learning goals (LG) and the influence on LG recall and implementation in medical students. METHODS: Following a standardized patient (SP) assessment, 168 pre-clinical medical students completed a SA, received SP feedback and created a LG. LG were categorized by source. Two weeks later, students recalled LG and described implementation. Chi-squared analyses were used to test the associations. RESULTS: SA influenced LG for 82.8% of students whereas SP feedback influenced LG for 45.9%. Students rarely generated LG based on SA when they received discordant feedback (5.4%), but sometimes incorporated feedback discordant from their SA into LG (14.9%). Students who created LG based on SP feedback were more likely to recall LG than those who created LG based on SA, 89.7 versus 67.6%, p < 0.05 and implement their LG, 72.4 versus 48.9%, χ2(1) = 5.3, p = 0.017. Students who reported receiving effective feedback were more likely to implement their LG than those reporting adequate feedback, 60.9 versus 37.9%, χ2(1) = 8.0, p = 0.01. CONCLUSIONS: SA is an essential part of goal setting and subsequent action. Perception of feedback plays a crucial role in LG implementation.

Coaching to improve self-directed learning.

BACKGROUND: The continuously changing health care context necesitates that medical trainees develop self-directed learning skills. This study examined the effect of coaching on the self-directed learning process in pre-clerkship medical students. METHODS: We conducted a longitudinal educational intervention using standardised patient assessments to determine the effect of self-assessment, feedback, and coaching on the development and implementation of learning goals (LGs). Students were sorted into control and intervention groups. Following each assessment, students received feedback on performance and created LGs. Students in the intervention group worked with a faculty member coach on their LGs. Students in the control group developed their LGs without a coach. Prior to the final assessment, students reported whether they had implemented their LGs. RESULTS: Of 171 students enrolled, 167 completed all four assessments and were included. All 167 developed an LG after each assessment. Overall, 79.0% of students reported implementing an LG. Of students receiving coaching, 91.8% implemented an LG, whereas only 65.9% of students in the control group implemented an LG (odds ratio, OR 5.7; 95% confidence interval, CI 2.4-14.2). Students who received coaching were more likely to incorporate performance feedback into their LGs (90.2 versus 38.1%; p < 0.05). CONCLUSIONS: For students, faculty member coaching facilitated better LG development and more frequent implementation compared with students who did not receive coaching.

Does Performance on Evidence-Based Medicine and Urgent Clinical Scenarios Assessments Deteriorate During the Fourth Year of Medical School? Findings From One Institution.

PURPOSE: The fourth year of medical school (M4) should prepare students for residency yet remains generally unstructured, with ill-defined goals. The primary aim of this study was to determine whether there were performance changes in evidence-based medicine (EBM) and urgent clinical scenarios (UCS) assessments before and after M4 year. METHOD: University of Michigan Medical School graduates who matched into internship at Michigan Medicine completed identical assessments on EBM and UCS at the beginning of M4 year and 13 months later during postgraduate year 1 (PGY1) orientation. Individual scores on these assessments were compared using paired t test analysis. The associations of academic performance, residency specialty classification, and initial performance on knowledge changes were analyzed. RESULTS: During academic years 2014 and 2015, 76 students matched into a Michigan Medicine internship; 52 completed identical EBM stations and 53 completed UCS stations. Learners' performance on the EBM assessment decreased from M4 to PGY1 (mean 93% [SD = 7%] vs. mean 80% [SD = 13%], P < .01), while performance on UCS remained stable (mean 80% [SD = 9%] vs. mean 82% [SD = 8%], P = .22). High M4 performers experienced a greater rate of decline in knowledge level compared with low M4 performers for EBM (-20% vs. -4%, P = .01). Residency specialty and academic performance did not affect performance. CONCLUSIONS: This study demonstrated degradation of performance in EBM during the fourth year and adds to the growing literature that highlights the need for curricular reform during this year.

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.

A Randomized Cohort Study of Diagnostic and Therapeutic Thresholds in Medical Student Clinical Reasoning.

PURPOSE: Learning to make decisions under uncertain conditions is a critical component of diagnostic and therapeutic reasoning. This study sought to determine treatment decisions medical students make when presented with different thresholds of diagnostic uncertainty and whether they appropriately adjust diagnostic probabilities with test information. METHOD: Two classes (2015, 2016) of fourth-year students (N = 342) were presented a patient with viral pneumonia and given 10%, 20%, or 50% pretest probabilities of that patient having a superimposed bacterial infection. Students decided to not treat, order a diagnostic test to guide management, or treat without testing based on these probabilities. The 2015 class was provided a posttest probability of 10% or 50% and asked to adjust their initial treatment decision. RESULTS: When given a low (10%) pretest probability, students were less likely to decide to treat (6%) and more likely to decide not to treat (36%). The percentage of students deciding to treat increased as the pretest probability of a superimposed infection increased from 10% to 50%, while the percentage of students not wanting to treat decreased. Interestingly, at 10%, 20%, and 50% pretest probability levels, most students were unable to decide and chose to order another test (57%, 67%, and 64%, respectively). When provided low and high posttest probabilities, students appropriately adjusted their decision making, but 29% to 32% still wanted additional testing. CONCLUSIONS: Students adjusted treatment decisions to reflect different levels of diagnostic uncertainty, but varied considerably in their individual thresholds to make decisions, possibly contributing to unnecessary testing.

Dental and dental hygiene students' perceptions of a standardized patient instructor conflict resolution program.

The aim of this study was to examine students' perceptions of the value of a standardized patient instructor conflict resolution program designed to strengthen their communication and confidence during difficult patient conversations. Three cohorts of students at one dental school were part of the study: the dental class of 2013, the dental class of 2014, and the dental hygiene class of 2013. The same groups of students completed surveys immediately following the program and one, two, or three years afterwards. Response rates for the survey immediately after the program were 98 percent (n=99) of the dental class of 2013, 97 percent (n=103) of the dental class of 2014, and 100 percent (n=25) of the dental hygiene class of 2013. Response rates for the subsequent survey were 41.5 percent (n=42) of the dental class of 2013, 74.5 percent (n=79) of the dental class of 2014, and 100 percent (n=25) of the dental hygiene class of 2013. In the results, all students reported a high level of satisfaction in their immediate assessment of the program and its ability to prepare them for conflict situations. They also reported a high level of satisfaction in their retrospective self-assessment of conflict resolution skills. However, their assessment of the program's value and applicability appeared to have diminished over time. This study suggests that the program should continue being a part of both dental and dental hygiene curricula, with more training and guided experiences in self-assessment and perhaps supplemental experiences added.