"Am I cut out for this?" Understanding the experience of doubt among first-year medical students.

PURPOSE: Existing research shows that medical students experience high levels of distress. The purpose of this study was to understand how medical students experience doubt, and how doubt relates to distress. METHODS: A mixed-methods study was conducted among first-year students at the Johns Hopkins University School of Medicine in June 2012. Students answered survey questions and participated in focus groups about doubt and other forms of distress. RESULTS: Ninety-four percent (112) of students responded to the survey, with 49% reporting a moderate or high degree of doubt. Compared to those reporting no or low doubt, students with moderate/high doubt were significantly more likely to question their purpose and identity, struggle to cope with doubt, and experience depression and emotional hardening. Twenty-eight percent of students (34/112) participated in focus groups to explore their doubt, and three themes emerged: types of doubt, ways of coping with doubt, and impact of doubt. CONCLUSIONS: Doubt is highly prevalent among first-year medical students, affects their identity and purpose, and has positive and negative consequences. Doubt among medical students merits awareness and further study, as it may be an important mediator of students' emerging identity and sense of well-being.

Benefits to faculty involved in medical school learning communities.

PURPOSE: Job satisfaction plays a large role in enhancing retention and minimizing loss of physicians from careers in academic medicine. The authors explored the effect of learning communities (LCs) on the faculty members' job satisfaction. METHODS: Between October 2011 and May 2012, the authors surveyed 150 academic clinical faculty members serving as LC mentors for students at five US medical schools. Factor analysis was used to explore satisfaction themes and relationships between these themes and other characteristics. RESULTS: Factor analysis revealed two major sources of this satisfaction: a Campus Engagement factor (e.g., feeling happier, improved sense of community, better communication skills, and feeling more productive) and a skills factor (e.g., improved clinical skills, being a better doctor). Higher Campus Engagement factor satisfaction was associated with less desire to leave the learning community (p = 0.01) and more FTE support for role in LC (p = 0.01). Higher skills factor satisfaction was associated with the school that provided more structured faculty development (p = 0.0001). CONCLUSION: Academic clinical faculty members reported serving as a mentor in an LC was a strong source of job satisfaction. LC may be a tool for retaining clinical faculty members in academic careers.

Learning environment assessments of a single curriculum being taught at two medical schools 10,000 miles apart.

BACKGROUND: Perdana University Graduate School of Medicine (PUGSOM), the first graduate-entry medical school in Malaysia, was established in 2011 in collaboration with Johns Hopkins University School of Medicine (JHUSOM), an American medical school. This study compared learning environments (LE) at these two schools, which shared the same overarching curriculum, along with a comparator Malaysian medical school, Cyberjaya University College of Medical Sciences (CUCMS). As a secondary aim, we compared 2 LE assessment tools - the widely-used Dundee Ready Educational Environment Measure (DREEM) and the newer Johns Hopkins Learning Environment Scale (JHLES). METHODS: Students responded anonymously at the end of their first year of medical school to surveys which included DREEM, JHLES, single-item global LE assessment variables, and demographics questions. RESULTS: Respondents included 24/24 (100 %) students at PUGSOM, 100/120 (83 %) at JHUSOM, and 79/83 (95 %) at CUCMS. PUGSOM had the highest overall LE ratings (p < 0.05) [DREEM 155.3 (SD 21.3); JHLES 116.5 (SD 12.2)], followed by JHUSOM [DREEM 143.3 (SD 22.5); JHLES 111.7 (SD 12.0)] and CUCMS [DREEM 138.5 (SD 22.4); JHLES 106.4 (SD 14.5)]. PUGSOM's overall high LE ratings were driven by responses in "perception of teaching," "meaningful engagement," and "acceptance and safety" domains. JHLES detected significant differences across schools in 5/7 domains and had stronger correlations than DREEM to each global LE assessment variable. CONCLUSIONS: The inaugural class of medical students at PUGSOM rated their LE exceptionally highly, providing evidence that transporting a medical school curriculum may be successful. The JHLES showed promise as a LE assessment tool for use in international settings.

Validation of the Polish version of the Johns Hopkins Learning Environment Scale-a confirmatory factor analysis.

The Johns Hopkins Learning Environment Scale (JHLES) was developed by Robert B. Shochet, Jorie M. Colbert and Scott M. Wright of the Johns hopkins university school of medicine and consists of 28 items used to evaluate perception of the academic environment. The objective was to translate and adapt the JHLES to Polish cultural conditions and to validate the Polish version of the tool. The JHLES questionnaire was completed by students of all years (first-fifth) of the faculties of dental medicine at the Medical University of Lublin and the Medical University of Gdansk. The total surveyed population consisted of 597 students. The overall reliability of the tool was excellent. Confirmatory factor analysis was performed in order to confirm structural consistency with the original JHLES tool. Consequently, all indices had acceptable values (close to 1 or 0, depending on the case), and there was consistency in the results, which shows that the JHLES model is supported by the data. In the present study, the JHLES has been validated in a sample of dental students for the first time in Poland and Europe. Our study provided good evidence for the reliability and validity of the Polish version of the JHLES. In conclusion, the Polish-language version of the JHLES questionnaire is a reliable and valid instrument for analysing the learning environment for students, and its factor structure is supported by the data.

Impact of a fitness intervention on medical students.

OBJECTIVE: It is known that regular exercise improves both physical and mental health. This study sought to determine the impact of a fitness intervention on the levels of exercise and well-being of medical students. METHODS: In 2011, the authors conducted a prospective cohort study involving medical students at the Johns Hopkins School of Medicine. Intervention students experienced a 7-week, team-based, fitness competition and recorded exercise data online. Incentives were given to teams reaching an average of 150 minutes per teammate per week, an exercise goal recommended by the US Department of Health and Human Services. Both groups completed baseline and follow-up surveys about physical activity and well-being, using validated scoring methods. RESULTS: A total of 100 students (71 in the intervention group and 29 in the control group) participated fully, recording their exercise behaviors and completing both the pre- and postsurveys. In the intervention group, the percentage of individuals successfully reaching the exercise target of 150 minutes per week varied by week from 30% to 61%. Intervention students showed a significant improvement in their International Physical Activity Questionnaire scores (1669.4 ± 154.9 vs 2013.6 ± 174.6; P = 0.02) and levels of irritability on the subsection of the Positive Affect and Negative Affect Scale score (2.2 ± 0.1 vs 2.0 ± 0.1, P = 0.03). By contrast, the control group did not show any improvements in any of these measures across the same time period (all P > 0.05). CONCLUSIONS: A well-orchestrated student-designed fitness intervention can effectively augment medical students' exercise practices and positively affect well-being.

Recognizing Reflection: Computer-Assisted Analysis of First Year Medical Students' Reflective Writing.

BACKGROUND: Reflective writing is used throughout medical education to help students navigate their transformation into medical professionals. Assessment of reflective writing, however, is challenging; each available methodology of assessment has distinct advantages and disadvantages. We tested if combining two independent assessment mechanisms-a faculty-designed rubric and Academic Writing Analytics (AWA), an automated technique-could be used together to form a more robust form of evaluation. METHODS: We obtained reflective essays written by first year medical students as part of a clinical skills course. Faculty scored essays using a rubric designed to evaluate Integration, Depth, and Writing. The same essays were subjected to AWA analysis, which counted the number of reflective phrases indicative of Context, Challenge, or Change. RESULTS: Faculty scored the essays uniformly high, indicating that most students met the standard for reflection as described by the rubric. AWA identified over 1400 instances of reflective behavior within the essays, and there was significant variability in how often different types of reflective phrases were used by individual students. CONCLUSIONS: While data from faculty assessment or AWA alone is sufficient to evaluate reflective essays, combining these methods offer a richer and more valuable understanding of the student's reflection.

Medical student engagement and leadership within a new learning community.

BACKGROUND: Many medical schools are establishing learning communities to foster cohesion among students and to strengthen relationships between students and faculty members. Emerging learning communities require nurturing and attention; this represents an opportunity wherein medical students can become involved as leaders. This study sought to understand issues related to active involvement among students who chose to become highly engaged in a newly developed learning community. METHODS: Between April and June 2008, 36 students who assumed leadership roles within the Colleges Program were queried electronically with open-ended questions about their engagement. Qualitative analysis of the written responses was independently performed by two investigators; coding was compared for agreement. Content analysis identified major themes. RESULTS: 35 students (97%) completed the questionnaire. Motives that emerged as reasons for getting involved included: endorsing the need for the program; excitement with the start-up; wanting to give back; commitment to institutional excellence; and collaboration with talented peers and faculty. Perceived benefits were grouped under the following domains: connecting with others; mentoring; learning new skills; and recognition. The most frequently identified drawbacks were the time commitment and the opportunity costs. Ideas for drawing medical students into new endeavors included: creating defined roles; offering a breadth of opportunities; empowering students with responsibility; and making them feel valued. CONCLUSIONS: Medical students were drawn to and took on leadership roles in a medical school curricular innovation. This example may prove helpful to others hoping to engage students as leaders in learning communities at their schools or those wishing to augment student involvement in other programs.

Measuring Students' Perceptions of the Medical School Learning Environment: Translation, Transcultural Adaptation, and Validation of 2 Instruments to the Brazilian Portuguese Language.

BACKGROUND: Although learning environment (LE) is an important component of medical training, there are few instruments to investigate LE in Latin American and Brazilian medical schools. Therefore, this study aims to translate, adapt transculturally, and validate the Medical School Learning Environment Scale (MSLES) and the Johns Hopkins Learning Environment Scale (JHLES) to the Brazilian Portuguese language. METHOD: This study was carried out between June 2016 and October 2017. Both scales have been translated and cross-culturally adapted to Brazilian Portuguese Language and then back translated and approved by the original authors. A principal components analysis (PCA) was performed for both the MSLES and the JHLES. Test-retest reliability was assessed by comparing the first administration of the MSLES and the JHLES with a second administration 45 days later. Validity was assessed by comparing the MSLES and the JHLES with 2 overall LE perception questions; a sociodemographic questionnaire; and the Depression, Anxiety, and Stress Scale (DASS-21). RESULTS: A total of 248 out of 334 (74.2%) first- to third-year medical students from a Brazilian public university were included. Principal component analysis generated 4 factors for MSLES and 7 factors for JHLES. Both showed good reliability for the total scale (MSLES α = .809; JHLES α = .901), as well as for each subdomain. Concurrent and convergent validity were observed by the strong correlations found between both scale totals (r = 0.749), as well as with both general LE questions: recommend the school to a friend (MSLES: r = 0.321; JHLES: r = 0.457) and overall LE rating (MSLES: r = 0.505; JHLES: r = 0.579). The 45-day test-retest comparison resulted in a Pearson correlation coefficient of 0.697 for the JHLES and 0.757 for the MSLES. CONCLUSIONS: Reliability and validity have been demonstrated for both the MSLES and the JHLES. Thus, both represent feasible options for measuring LE in Brazilian medical students.

Cloaking as a Community: Re-imagining the White Coat Ceremony With a Medical School Learning Community.

The Johns Hopkins School of Medicine's Learning Community-White Coat Ceremony (LC-WCC) is held each spring as a learning community (LC) event. Learning communities (LCs) connect people to learn and work across boundaries to achieve a shared goal. The LC-WCC invites first-year students to collaborate with school leaders, define the class professional values, and innovate with community members. Class-elected student leaders recruit peers to join committees to plan and lead several aspects of the ceremony, including a class-nominated speaker, a personal statements presentation, a patient inclusion presentation, a class-authored statement of values, and artistic performances. Student cloaking is performed by LC advisors in their LC small groups. A 2015 post-LC-WCC survey asking students to compare experiences of a traditional Stethoscope Ceremony (SC) with the LC-WCC found that the latter significantly increased students' sense of accomplishment (38% vs 68%, P < .001), sense of connection to the school (59% vs 82%, P < .001), to classmates (71% vs 93%, P < .001), and to the event (42% vs 76%, P < .001). Cloaking as a community is an effective way for a medical school LC to instill a greater sense of community and student leadership in this milestone celebration of humanistic values in medicine.

Defining Learning Communities in Undergraduate Medical Education: A National Study.

BACKGROUND: Learning communities (LCs) are intentionally designed groups that are actively engaged in learning with and from each other. While gaining prominence in US medical schools, LCs show significant variability in their characteristics across institutions, creating uncertainty about how best to measure their effects. OBJECTIVE: The aim of this study is to describe the characteristics of medical school LCs by primary purpose, structures, and processes and lay the groundwork for future outcome studies and benchmarking for best practices. METHODS: Medical school LC directors from programs affiliated with the Learning Communities Institute (LCI) were sent an online survey of program demographics and activities, and asked to upload a program description or summary of the LC's purpose, goals, and how it functions. Descriptive statistics were computed for survey responses and a qualitative content analysis was performed on program descriptions by 3 authors to identify and categorize emergent themes. RESULTS: Of 28 medical school LCs surveyed, 96% (27) responded, and 25 (89%) provided program descriptions for qualitative content analysis. All programs reported longitudinal relationships between students and faculty. Most frequently cited objectives were advising or mentoring (100%), professional development (96%), courses (96%), social activities (85%), and wellness (82%). Primary purpose themes were supporting students' professional development, fostering a sense of community, and creating a sense of wholeness. Structures included a community framework, subdivisions into smaller units, and governance by faculty and students. Process themes included longitudinal relationships, integrating faculty roles, and connecting students across class years. CONCLUSIONS: Medical school LCs represent a collection of high-impact educational practices characterized by community and small-group structures, relational continuity, and collaborative learning as a means to guide and holistically support students in their learning and development as physicians. In describing 27 medical school LCs, this study proposes a unifying framework to facilitate future educational outcomes studies across institutions.

Beyond words: What can help first year medical students practice effective empathic communication?

OBJECTIVE: To gain insight into first year medical students' experiences of practicing empathic communication and how patients that train students perceive such communication, in order to inform early communication skills training. METHODS: Our study consisted of four focus groups, two of year one students who completed a first semester clinical skills course, one of standardized patients, and one of volunteer outpatients. Focus group transcripts were independently coded and iteratively reviewed to identify major themes. Course evaluation data was collected and analyzed. RESULTS: Themes from student focus groups described significant challenges in striving to convey empathy: coping with anxiety due to multitasking, "buying-in" to learning empathy, and managing vulnerability when engaging emotionally. Patients appreciated students' expression of vulnerability and nonverbal communication. CONCLUSION: First year medical students encounter challenges in learning empathic communication, and patients may perceive empathy from students in ways other than verbal responses. Early communications curricula should focus on assisting students with anxiety of multi-tasking, sense of vulnerability, buy-in to communications training, and the importance of non-verbal communication. PRACTICE IMPLICATIONS: A deliberate focus on empathetic responsiveness, especially non-verbal, might lessen anxiety, improve attentional switching, and build confidence in managing vulnerability for early medical students learning communication skills.

Associations between learning community engagement and burnout, quality of life, and empathy among medical students.

OBJECTIVES: To inform evidence-based design and implementation of medical school learning communities (LCs) by investigating which LC components medical students at one school with a multi-component LC were most valued and which were associated with desirable outcomes. METHODS: In this cross-sectional study, all Johns Hopkins School of Medicine (JHSOM) students were surveyed in Spring 2016 regarding perceived value of LC components (peers, faculty advisors, Clinical Foundations of Medicine (CFM) clinical skills course, quarterly reflective discussion sessions, social activities, and LC rooms) with learning environment (LE) perceptions, quality of life, burnout, and empathy assessed as outcomes. Multivariate logistic regressions analyzed associations between LC components and outcomes. RESULTS: Overall 368/480 (77%) students responded.  CFM was highly valued by 286 (80%) students, advisors by 277 (75%).  All LC components were significantly associated with favorable overall LE perceptions, but associations with LE subdomains varied.  CFM was the only LC component to have significant associations with greater empathic concern (OR 2.1, 95% CI=1.2-3.7) and perspective-taking (OR 1.8, 95% CI=1.0-3.1), less emotional exhaustion (OR 0.4, 95% CI=0.2-0.6) and depersonalization (OR 0.3, 95% CI=0.1-0.5), and good quality of life (OR 3.7, 95% CI=1.9-7.1).  Every other LC component, except LC rooms, was associated with greater empathy or enhanced well-being. CONCLUSIONS: Components within an LC are valued differently and vary in their relationships with student outcomes.  Future LC research may isolate the effects of and explore interactions among different LC components, leading to more purposeful LC design and allocation of resources.

An association between paying physician-teachers for their teaching efforts and an improved educational experience for learners.

BACKGROUND: Medical schools often rely on faculty volunteerism to address clinical teaching needs for students. Increasing time pressures on physicians has made it difficult to secure commitments for clinical instruction. In the 2005-2006 academic year, the Johns Hopkins University School of Medicine (JHUSOM) launched the Colleges Program, recruiting 24 salary-supported physician-faculty to serve as advisors to students as well as teachers of the second year course, 'clinical skills'. We hypothesized that compensating physician educators would have a measurable positive impact on the students' experiences in this course. MATERIALS AND METHODS: Students' assessments of paid colleges faculty (CF) preceptors from the 2005-2006 year were compared to those of volunteer preceptors from the two prior years (2003-2005 academic years) along six different teaching parameters linked to the course's objectives. Multivariable regression analysis was used to identify the factors independently associated with higher preceptor scores. RESULTS: Fifty-eight preceptors taught clinical skills over the 3-year study period. The overall response rate for preceptor evaluations by medical learners was 77% (277/359). CF, more likely than volunteer preceptors to have a full-time academic appointment (100 vs 63%, p < .01), have an additional advanced degree (48 vs 15%, p < .01) and prior faculty development training (52 vs 17%, p < .01). Scores for all six evaluation domains were higher for CF compared to those from the two previous years combined (all p < .001). In the fully adjusted regression model, only CF status was independently associated with high preceptor evaluation scores (Odds Ratio 4.3, 95% CI 1.01-18.20). CONCLUSIONS: Salary support for teaching efforts in the time-intensive CS course coupled with the prestige of being appointed to the CF was associated with higher student evaluations.

The new and improved learning community at Johns Hopkins University School of Medicine resembles that at Hogwarts School of Witchcraft and Wizardry.

BACKGROUND: In July 2005, a learning community was created at Johns Hopkins University School of Medicine (JHUSOM) to foster camaraderie, networking, advising, mentoring, professionalism, clinical skills, and scholarship--The Colleges. The cultural and structural changes that emerged with the creation of this program have resulted in JHUSOM bearing a resemblance to J. K. Rowling's fictional Hogwarts School of Witchcraft and Wizardry. AIMS: This manuscript will describe the similarities between these two revered schools, and highlight the innovations and improvements made to JHUSOM's learning environment. DESCRIPTION: The intense, stressful, and lengthy professional training required to achieve competency in the practice of medicine and in the practice of witchcraft (albeit fictional) have meaningful parallels. CONCLUSION: The supportive learning environment at these two schools should afford the next generation of graduates to have an even more enriching experience than those who have come before them.

Peer-Led, Postanatomy Reflection Exercise in Dissection Teams: Curriculum and Training Materials.

INTRODUCTION: The importance of emphasizing empathy, reflection, and professionalism during anatomy dissection has been well established. This small-group curriculum was developed to fulfill a need for structured reflection at the end of anatomy. METHODS: In this 45-minute reflection session, each dissection team of first-year medical students in anatomy is led by one or two peer facilitators recruited from the second-year medical student class. The session is designed to include a time for sharing of personal reflections, a clinical observation activity about the cadaver's cause of death, and an appreciative inquiry approach to the dissection team experience. In addition to the reflection session curriculum, materials also include a 1-hour presession training module, containing a small-group facilitator skill-building and role-play and a 30-minute postsession debrief for peer facilitators. RESULTS: We found that the majority of anatomy students felt that the end-of-course reflection was a meaningful way to conclude the course and that the session had a positive impact on their relationship with their dissection team. Fifteen peer facilitators participated in focus groups, and common themes included the value of giving back, making meaning of past experiences, countering burnout by recognizing one's own growth, and continued learning through peer teaching. DISCUSSION: This anatomy reflection curriculum has been incorporated into our 7-week anatomy course and has been well received by both anatomy students and peer facilitators. We believe that peer-led small-group reflection sessions after intensive experiences in medical school can promote personal and professional growth among both junior and senior medical students.

Back to the Future: What Learning Communities Offer to Medical Education.

Learning communities (LCs) have increasingly been incorporated into undergraduate medical education at a number of medical schools in the United States over the past decade. In an Association of Medical Colleges survey of 140 medical schools, 102 schools indicated that they had LC (described as colleges or mentorship groups; https://www.aamc.org/initiatives/cir/425510/19a.html). LCs share an overarching principle of establishing longitudinal relationships with students and faculty, but differ in the emphasis on specific components that may include curriculum delivery, advising/ mentoring, student wellness, and community. The creation of LCs requires institutional commitment to reorganize educational processes to become more student centered. LCs are beginning to show positive outcomes for students including benefits related to clinical skills development, advising, and student wellness, in addition to positive outcomes for LC faculty.

Does academic performance or personal growth share a stronger association with learning environment perception?

OBJECTIVES: This study was conducted to characterize the relative strength of associations of learning environment perception with academic performance and with personal growth. METHODS: In 2012-2014 second and third year students at Johns Hopkins University School of Medicine completed a learning environment survey and personal growth scale. Hierarchical linear regression analysis was employed to determine if the proportion of variance in learning environment scores accounted for by personal growth was significantly larger than the proportion accounted for by academic performance (course/clerkship grades). RESULTS: The proportion of variance in learning environment scores accounted for by personal growth was larger than the proportion accounted for by academic performance in year 2 [R(2)Δ of 0.09, F(1,175) = 14.99,  p < .001] and year 3 [R(2)Δ of 0.28, F(1,169) = 76.80, p < .001]. Learning environment scores shared a small amount of variance with academic performance in years 2 and 3.  The amount of variance between learning environment scores and personal growth was small in year 2 and large in year 3. CONCLUSIONS: Since supportive learning environments are essential for medical education, future work must determine if enhancing personal growth prior to and during the clerkship year will increase learning environment perception.