Vascular Surgery Curriculum for Medical Students: A National Targeted Needs Assessment.

BACKGROUND: At present, neither the American College of Surgeons (ACS) nor the Society for Vascular Surgery (SVS) provides curriculum recommendations for medical students rotating on a vascular surgery service. We sent a targeted needs assessment to vascular surgeons across the country in order to investigate the need for a structured curriculum for medical students participating in a vascular surgery rotation during their clinical clerkships. METHODS: The survey was developed with input from medical students, vascular surgeons, and medical educators. Respondents were identified from the Fellowship and Residency Electronic Interactive Database (FREIDA). The needs assessment was sent to program directors of vascular residencies and fellowships and to other vascular surgery educators. The survey collected data regarding the existing vascular surgery curriculum at the respondent's institution, the need for a standardized curriculum, desired experiences for medical students, and important vascular topics for medical students to cover while on rotation. RESULTS: Responses were obtained from 50 of the 146 surveyed individuals (response rate = 34.2%). 48 respondents (96%) worked in an academic hospital or academic affiliated hospital. With regard to the existing vascular surgery curriculum, only 28 respondents (61%) indicated that they had a curriculum approved by the surgery clerkship director. 37 respondents (77.1%) said there were at least goals and objectives for students on the vascular surgery service, and 29 respondents (60.4%) indicated that there was dedicated time for didactic sessions. Only 17 respondents (35.4%) indicated students gave a case presentation on the service. 29 respondents (63%) agreed or strongly agreed that there should be a standardized vascular curriculum for medical students. When asked to rank 9 topics from most important to least important for students to learn, respondents ranked peripheral arterial disease, aortic disease, and carotid disease highest. Simulation experience was most frequently indicated as a desired addition to the curriculum, and only 16 respondents (33.3%) reported opportunities for vascular surgery specific simulation experiences. CONCLUSIONS: This study identified the lack of an existing structured curriculum for medical students, the desire for a standardized curriculum, and key topics and experiences that are felt to be important for students to cover.  With this information in hand, vascular educators have the potential to enhance the learning experience of medical students rotating through the service by developing a standardized curriculum.

The impact of longitudinal integrated clerkships on patient care: a qualitative systematic review.

BACKGROUND: Longitudinal Integrated Clerkships (LIC) are a relatively novel type of clinical placement model within medical education, particularly within the UK. The research on LICs primarily focuses on the impact of the model on students, tutors, communities, and organisations. The impact of LICs on patients has not yet been adequately synthesised. This systematic review aims to fill this gap by examining empirical evidence regarding the impact of LICs on patient care using quality-of-care measures, namely, health process measures and outcome measures. METHODS: A systematic search was conducted in MEDLINE, PsycINFO, Academic Search Premier, Education Research Complete, CINAHL Complete, ERIC, Web of Science, and Scopus. Two reviewers independently conducted the screening process for study selection. Results across studies were analysed and summarised by thematic analysis. RESULTS: The reviewers screened 1632 records. Seven studies met the inclusion criteria following a full-text review, from which four themes were created. Three themes describe health process measures, including: 1) Advocacy within healthcare system, 2) Provision of supplementary and personalised care, and 3) Providing companionship with care. One theme described a health outcome measure: Therapeutic Alliance. CONCLUSION: Current evidence demonstrates an overall beneficial impact of LICs on patient health processes and outcome measures. However, the available evidence is weak and limited. Further research is required to illuminate the true impact of LICs on patient health.

Validating an Obstetrics and Gynaecology Longitudinal Integrated Clerkship Curriculum at the University of Toronto: A Four-Year Review.

The University of Toronto launched a longitudinal integrated clerkship (LIC) pilot project in 2014. Our aim was to evaluate LIC student outcomes in obstetrics and gynaecology compared with those of traditional block students. LIC and block students underwent identical evaluations, including written and oral exams, as well as clinical assessments from the ward. LIC student scores in each domain were compared with those of the traditional block students over 4 years. There were no differences in overall pass/fail status between LIC and block students. Thus, our LIC design could be appropriately modeled at other teaching institutions contemplating introducing an LIC stream.

Gathering Validity Evidence on an Internal Medicine Clerkship Multistep Exam to Assess Medical Student Analytic Ability.

Construct: The definition of clinical reasoning may vary among health profession educators. However, for the purpose of this paper, clinical reasoning is defined as the cognitive processes that are involved in the steps of information gathering, problem representation, generating a differential diagnosis, providing a diagnostic justification to arrive at a leading diagnosis, and formulating diagnostic and management plans. Background: Expert performance in clinical reasoning is essential for success as a physician, and has been difficult for clerkship directors to observe and quantify in a way that fosters the instruction and assessment of clinical reasoning. The purpose of this study was to gather validity evidence for the Multistep exam (MSX) format used by our medicine clerkship to assess analytical clinical reasoning abilities; we did this by examining the relationship between scores on the MSX and other external measures of clinical reasoning abilities. This analysis used dual process theory as the main theoretical framework of clinical reasoning, as well as aspects of Kane's validity framework to guide the selection of validity evidence for the investigation. We hypothesized that there would be an association between the MSX (a three-step clinical reasoning tool developed locally), and the USMLE Step 2 CS, as they share similar concepts in assessing the clinical reasoning of students. We examined the relationship between overall scores on the MSX and the Step 2 CS Integrated Clinical Encounter (ICE) score, in which the student articulates their reasoning for simulated patient cases, while controlling for examinee's internal medicine clerkship performance measures such as the NBME subject exam score and the Medicine clerkship OSCE score. Approach: A total 477 of 487 (97.9%) medical students, representing the graduating classes of 2015, 2016, 2017, who took the MSX at the end of each medicine clerkship (2012-2016), and Step 2 CS (2013-2017) were included in this study. Correlation analysis and multiple linear regression analysis were used to examine the impact of the primary explanatory variables of interest (MSX) onto the outcome variable (ICE score) when controlling for baseline variables (Medicine OSCE and NBME Medicine subject exam). Findings: The overall MSX score had a significant, positive correlation with the Step 2 CS ICE score (r = .26, P < .01). The overall MSX score was a significant predictor of Step 2 CS ICE score (ß = .19, P < .001), explaining an additional 4% of the variance of ICE beyond the NBME Medicine subject score and the Medicine OSCE score (Adjusted R2 = 13%). Conclusion: The stepwise format of the MSX provides a tool to observe clinical reasoning performance, which can be used in an assessment system to provide feedback to students on their analytical clinical reasoning. Future studies should focus on gaining additional validity evidence across different learners and multiple medical schools.

Why shouldn't we do that on placement if we're doing it in the real world? Differences between undergraduate and graduate identities in speech and language therapy.

Healthcare graduates are often characterised as ill-prepared for workplace entry. Historically, research on health professional's work preparedness has focused on the quality of graduates' clinical knowledge, skills and problem-solving. This ignores the role of professional identity formation in determining readiness for clinical practice. Yet, professional identity defines graduate self-perception, how others perceive them and informs clinical behaviour. The scholarship of identity formation at the transition from undergraduate to graduate is characterised by individual (cognitive) rather than relational (sociocultural) perspectives. Yet there is growing recognition that identity formation is not just individually mediated, but is also constructed between individuals and social context. The aim of this study was to explore professional identity formation among undergraduates and graduates from one healthcare profession (speech and language therapy-SLT) using a sociocultural theoretical standpoint. A qualitative descriptive methodology was used. Final (4th) year SLT undergraduate students and graduate SLTs with less than 2 years' clinical experience participated in individual semi-structured interviews. Thematic analysis was used to describe patterns in the data, which were subsequently subjected to interpretation informed by the constructs of Figured Worlds. Data analysis revealed that undergraduate professional identity was characterised by dependency, self-centredness (as opposed to patient-centredness), and a naïve role concept. Graduate identity on the other hand included expectations of self-sufficiency, patient-centredness and a more nuanced perception of the professional role. Undergraduates have naïve, prototypical understandings of what it is to be a graduate practitioner. The nature of undergraduate clinical placement hinders meaningful identity development. This suggests that curriculums should facilitate undergraduates to act with meaningful autonomy and to be positioned in more patient-centred roles, e.g. involvement in the decision-making process for patients. Graduates may then feel more authentic as autonomous professionals in their early graduate posts. This leads to better graduate, patient and service outcomes.

Exploring the Predictors of Post-Clerkship USMLE Step 1 Scores.

Theory: We used two theoretical frameworks for this study: a) experiential learning, whereby learners construct new knowledge based on prior experience, and learning grows out of a continuous process of reconstructing experience, and b) deliberate practice, whereby the use of testing (test-enhanced learning) promotes learning and produces better long-term retention. Hypothesis: We hypothesized that moving the USMLE Step 1 exam to follow the clerkship year would provide students with a context for basic science learning that may enhance exam performance. We also hypothesized that examination performance variables, specifically National Board of Medical Examiners (NBME) Customized Basic Science Examinations and NBME subject examinations in clinical disciplines would account for a moderate to large amount of the variance in Step 1 scores. Thus we examined predictors of USMLE Step 1 scores when taken after the core clerkship year. Method: In 2011, we revised our medical school curriculum and moved the timing of Step 1 to follow the clerkship year. We performed descriptive statistics, an ANCOVA to compare Step 1 mean scores for three graduating classes of medical students before and after the curriculum changes, and stepwise linear regression to investigate the association between independent variables and the primary outcome measure after curriculum changes. Results: 993 students took the Step 1 exam, which included graduating classes before (2012-2014, N = 491) and after (2015-2017, N = 502) the curriculum change. Step 1 scores increased significantly following curricular revision (mean 218, SD 18.2, vs. 228, SD 16.7, p < 0.01) after controlling for MCAT and undergraduate GPA. Overall, 66.4% of the variance in Step 1 scores after the clerkship year was explained by: the mean score on fourteen pre-clerkship customized NBME exams (p < 0.01, 57.0% R2); performance on the surgery NBME subject exam (p < 0.01, 3.0% R2); the pediatrics NBME subject exam (p < 0.01, 2.0% R2); the Comprehensive Basic Science Self-Assessment (p < .01, 2.0% R2) ; the internal medicine NBME subject exam (p < 0.01, 0.03% R2), pre-clerkship Integrated Clinical Skills score (p < 0.01, 0.05% R2), and the pre-matriculation MCAT (p < 0.01, 0.01% R2). Conclusion: In our institution, nearly two-thirds of the variance in performance on Step 1 taken after the clerkship year was explained mainly by pre-clerkship variables, with a smaller contribution emanating from clerkship measures. Further study is needed to uncover the specific aspects of the clerkship experience that might contribute to success on high stakes licensing exam performance.

Student Exposure to Cancer Patients: an Analysis of Clinical Logbooks and Focus Groups in Clinical Year Medical Students.

Despite cancer being the leading cause of mortality, cancer education and patient exposure are lacking in many medical schools. The aim of this study was to evaluate the nature of cancer patient exposure, relative to the clinical setting for medical students on placement and to explore their experiences. Participants were asked to maintain a logbook of cancer patient encounters and were invited to attend a structured focus group upon completion of the academic year. Eleven students submitted logbooks (rr = 6.15%) and eight participated in the focus groups (4.47%). A total of 247 cancer patient encounters were recorded. Third-year students primarily saw cancer patients in surgery (18.62%) and general practice (8.50%), whilst final year students saw cancer patients most frequently in palliative care (35.22%) and ENT surgery (13.77%). Students highlighted that the quality of their interactions with cancer patients varied significantly between clinical settings. Outpatient clinics and surgical in-patients had the lowest level of interaction, with students having a predominantly observatory role. Repeated themes of uncertainty and awkwardness regarding history, examination and discussing death and dying were outcomes of the thematic analysis. Exposure to cancer patients remains highly variable and opportunistic. Students voiced concerns for preparedness to practice and many found it worrisome that they will likely examine a primary cancer when they have graduated, without having done so during their training. Our study suggests that a more structured approach to teaching and clinical exposure to cancer patients is required.

Medical Student Exposure to Radiation Oncology Through the Pre-clerkship Residency Exploration Program (PREP): Effect on Career Interest and Understanding of Radiation Oncology.

Medical students receive little exposure to Radiation Oncology (RO) during pre-clinical training and clerkship. Pre-clerkship Residency Exploration Program (PREP) was developed by medical students at our institution to provide students with exposure to disciplines like RO with which they may not have had previous exposure, with the goal of helping with career decision making. The purpose of this study was to review how PREP affected self-reported interest in RO. PREP is a 2-week intensive elective developed by students at Dalhousie University that provides exposure to 12 specialties, including RO. PREP includes five components: half day clinical rotations, skills sessions, simulations, specialty-specific workshops, and lunchtime panel discussions. PREP participants completed questionnaires pre- and post-participation to assess career interest and understanding of Radiation Oncology. Forty participants took part in PREP. Thirty-six responded to pre-PREP questionnaires and 37 to the post-PREP questionnaire. Participants reported increasing interest in RO (24 students, 64.8%) and an increase in the understanding of the role and responsibilities of a radiation oncologist such that they felt comfortable making a career decision about RO. In pre-PREP, five (13.8%) participants listed RO as a top 3 career choice. Post-program, this number increased to nine (25.0%) of the same surveyed participants. PREP has demonstrated early exposure to RO can increase interest in RO as a career choice. Early clinical exposure experiences like we describe here may be useful for specialties such as RO, which is having difficulty filling residency positions in Canada despite an optimistic job forecast for trainees.

Exploring the relationship between resilience and practice education placement success in occupational therapy students.

INTRODUCTION: Practice education is a fundamental component of health professional students' education and many personal, social and professional factors impact on students' performance. This study investigated the relationship between measures of resilience and practice education performance in occupational therapy students. METHODS: A quantitative cross-sectional study was used to collect the data. In all, 149 occupational therapy students completed a self-report questionnaire comprised of demographic questions and two standardised scales: Resilience at University (RAU) and Resilience Scale for Adults (RSA). Students' practice education performance was measured by the Student Practice Evaluation Form-Revised (SPEF-R). Multi-linear regression analyses with bootstrapping were completed to identify resilience factors that were predictive of occupational therapy students' practice performance. RESULTS: Overall, occupational therapy students reported high levels of resilience based on the RAU and RSA subscale scores. "Managing Stress," "Find Your Calling" and "Living Authentically" were strong predictors of a range of key fieldwork performance SPEF-R factors, including "Professional Behaviours," "Self-management Skills," "Co-worker Communication" and "Communication Skills." CONCLUSION: The resilience factors identified as being significant predictors of practice education performance outcomes in occupational therapy students represent notable findings. They suggest that students' capabilities in managing their stress levels, finding meaning in their chosen profession, and engaging self-care daily activities outside of the work environment that are meaningful, authentic and fit with one's personal values and beliefs can act as buffers against the challenges experienced by students who are completing practice education placements. The findings will assist academic and practice educators in identifying and targeting vulnerable students and strengthening resilience strategies through proactive pre-practice placement initiatives. Qualitative studies are recommended to further explore the relationship between resilience and practice education performance in occupational therapy students.

Clerkship Ethics: Unique Ethical Challenges for Physicians-in-Training.

Three ethical conflicts in particular are paradigmatic of what we define as "clerkship ethics." First, a distinction that differentiates the clerkship student from the practicing physician involves the student's principal role as a learner. The clerkship student must skillfully balance her commitment to her own education against her commitment to patient care in a fashion that may compromise patient care. While the practicing physician can often resolve the tension between these two goods when they come into conflict, the clerkship student is left with a more ambiguous set of choices. Second, evaluative scrutiny during clinical clerkships often forces medical students to balance doing what is morally fitting against the perceived expectations of the medical teams in which they work. Third and finally, a deeply entrenched culture of medical hierarchy presents a particular challenge to innovation and improvement in ethics education during the clerkship years. Students regard faculty as exemplars, but are not provided with the tools to assess when technical medical competence is not matched by moral competence; moreover, these faculty are unlikely to have experienced the ethics education in which students are asked to demonstrate mastery.

Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey.

BACKGROUND: Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic. OBJECTIVE: To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation. DESIGN: National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018. MAIN MEASURES: The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons. KEY RESULTS: The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%). CONCLUSIONS: Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.

Broadly sampled assessment reduces ethnicity-related differences in clinical grades.

CONTEXT: Ethnicity-related differences in clinical grades exist. Broad sampling in assessment of clinical competencies involves multiple assessments used by multiple assessors across multiple moments. Broad sampling in assessment potentially reduces irrelevant variances and may therefore mitigate ethnic disparities in clinical grades. OBJECTIVES: Research question 1 (RQ1): to assess whether the relationship between students' ethnicity and clinical grades is weaker in a broadly sampled versus a global assessment. Research question 2 (RQ2): to assess whether larger ethnicity-related differences in grades occur when supervisors are given the opportunity to deviate from the broadly sampled assessment score. METHODS: Students' ethnicity was classified as Turkish/Moroccan/African, Surinamese/Antillean, Asian, Western, and native Dutch. RQ1: 1667 students (74.3% native Dutch students) were included, who entered medical school between 2002 and 2004 (global assessment, 818 students) and between 2008 and 2010 (broadly sampled assessment, 849 students). The main outcome measure was whether or not students received ≥3 times a grade of 8 or higher on a scale from 1 to 10 in five clerkships. RQ2: 849 students (72.4% native Dutch students) were included, who were assessed by broad sampling. The main outcome measure was the number of grade points by which supervisors had deviated from broadly sampled scores. Both analyses were adjusted for gender, age, (im)migration status and average bachelor grade. RESULTS: Research question 1: ethnicity-related differences in clinical grades were smaller in broadly sampled than in global assessment, and this was also seen after adjustments. More specifically, native Dutch students had reduced probabilities (0.87-0.65) in broadly sampled as compared with global assessment, whereas Surinamese (0.03-0.51) and Asian students (0.21-0.30) had increased probabilities of having ≥3 times a grade of 8 or higher in five clerkships. Research question 2: when supervisors were allowed to deviate from original grades, ethnicity-related differences in clinical grades were reintroduced. CONCLUSIONS: Broadly sampled assessment reduces ethnicity-related differences in grades.

Assessing Preceptor Use of Cognitive Apprenticeship: Is the Maastricht Clinical Teaching Questionnaire (MCTQ) a Useful Approach?

Construct: The authors investigated the utility of the Maastricht Clinical Teaching Questionnaire (MCTQ) to assess preceptor use of cognitive apprenticeship teaching methods. Background: The MCTQ is an instrument first studied in medical and veterinary education; it was shown to produce valid and reliable data when evaluating how well preceptors engage in cognitive apprenticeship. Additional validity evidence, however, is needed to determine if the MCTQ is useful and applicable in other healthcare professions, such as pharmacy. Approach: Student pharmacists and pharmacy residents at a large academic medical center completed the MCTQ to evaluate pharmacist preceptors. A confirmatory factor analysis (CFA) was used to determine how consistent the data were with the 5-factor structure of the cognitive apprenticeship teaching methods (e.g., modeling, coaching, articulation, exploration, and safe learning environment). A structural equation model (SEM) was used to evaluate the relationship between the 5 factors. Preceptor and student perceptions were also collected to evaluate the response process and potential consequences of using the instrument. Results: Thirty-eight learners (2nd-year and 4th-year student pharmacists and pharmacy residents) submitted 157 evaluations. The CFA showed appreciable fit with the 5-factor structure of the cognitive apprenticeship framework after 2 modifications (removal of 1 item and moving 1 item to a different factor). The SEM had poor model fit compared to previous studies, and an exploratory analysis suggests that there is a complex relationship between the various teaching methods. Preceptors and students highly agreed that the instrument was valuable for providing feedback. Conclusion: The MCTQ has additional validity evidence that supports it as a viable instrument to assess preceptor engagement in teaching methods consistent with the cognitive apprenticeship framework. Additional research is warranted to explore the relationship between components in the cognitive apprenticeship framework to determine how preceptors can best focus their efforts to improve clinical teaching.

Effectiveness of SNAPPS for improving clinical reasoning in postgraduates: randomized controlled trial.

BACKGROUND: In-patient postgraduate teaching suffers with issues like long and unstructured presentations inclusive of a lot of historical information and time constraints due to increasing workload. A six-step pneumonic SNAPPS a learner-centered model modifies the learning encounter by condensing the reporting of facts while encouraging clinical reasoning. This study was planned with the aim to evaluate the effectiveness of SNAPPS as compared to traditional case presentation for facilitating clinical reasoning in inpatient setting. We also wanted to understand perceptions of postgraduates and teachers about this new method of case presentation. METHODS: This open labeled randomized controlled trial was carried amongst the 18 residents of department of Medicine, MGIMS. The teachers and residents in the SNAPPS were sensitized to SNAPPS technique by using videos, role plays and handouts over 2 sessions of 30 min each. Twenty-seven case presentations (3/resident) were carried out in each group (total 54 case presentations). Data was recorded into validated data recording sheet after each presentation and feedback was taken from the teacher as well as residents regarding their perception. RESULTS: The SNAPPS model heralds a change in the preceptor training, pairing faulty development and learner development as companions in education. Guided by the SNAPPS technique, students summarized patient findings concisely (7 vs. 2.7 vs. 5.22vs. 2.33, p = 0.0057) while maintaining the same degree of thoroughness as in traditional case presentations. The students in the SNAPPS group were clearer about their diagnostic hypothesis and compared and contrasted their different diagnosis well (2.56 vs. 1.74, p value =0.002). The students in the SNAPPS group initiated patient management discussion almost 20% more times as compared to the control group. CONCLUSION: We conclude that SNAPPS a learner centered technique for case presentations facilitated the expression of clinical diagnostic reasoning and case based uncertainties in the inpatient setting without extending the unusual length of the student case presentations. It also paved way for enhanced self-directed learning.

Barriers and facilitators to writing quality items for medical school assessments - a scoping review.

BACKGROUND: Producing a sufficient quantity of quality items for use in medical school examinations is a continuing challenge in medical education. We conducted this scoping review to identify barriers and facilitators to writing good quality items and note gaps in the literature that are yet to be addressed. METHODS: We conducted searches of three databases (ERIC, Medline and Scopus) as well as Google Scholar for empirical studies on the barriers and facilitators for writing good quality items for medical school examinations. RESULTS: The initial search yielded 1997 articles. After applying pre-determined criteria, 13 articles were selected for the scoping review. Included studies could be broadly categorised into studies that attempted to directly investigate the barriers and facilitators and studies that provided implicit evidence. Key findings were that faculty development and quality assurance were facilitators of good quality item writing while barriers at both an individual and institutional level include motivation, time constraints and scheduling. CONCLUSIONS: Although studies identified factors that may improve or negatively impact on the quality of items written by faculty and clinicians, there was limited research investigating the barriers and facilitators for individual item writers. Investigating these challenges could lead to more targeted and effective interventions to improve both the quality and quantity of assessment items.

The role of vertically integrated learning in a rural longitudinal integrated clerkship.

BACKGROUND: Deakin's Rural Community Clinical School (RCCS) is a Longitudinal Integrated Clerkship (LIC) program in Western Victoria. Students undertake a year-long placement in a rural General Practice, many of which also host General Practice Registrars. There is a lack of evidence addressing the role and impact of Vertically Integrated Learning (VI) in practices hosting both LIC medical students and General Practice Registrars. The objective of the study was to establish how VI is perceived in the LIC context and the impact that it has on both learners and practices, in order to consider how to potentiate the role it can play in facilitating learning. METHODS: Semi-structured, in-depth, qualitative interviews were undertaken, with 15 participants located in RCCS General Practices. Emergent themes were identified by thematic analysis. RESULTS: Five main interconnected themes were identified; (i) understanding and structure, (ii) planning and evaluation, (iii) benefits, (iv) facilitators, and (v) barriers. CONCLUSION: VI in a rural LIC is not clearly understood, even by participants. VI structure and methodology varied considerably between practices. Benefits included satisfying and efficient sharing of knowledge between learners at different levels. VI was facilitated by the supportive and collegiate environment identified as being present in a rural LIC context. Resources for VI are needed to guide content and expectations across the continuum of medical training and evaluate its role. The financial impact of VI in a rural LIC warrants further exploration.

Designing faculty development: lessons learnt from a qualitative interpretivist study exploring students' expectations and experiences of clinical teaching.

BACKGROUND: Clinical teaching plays a crucial role in the transition of medical students into the world of professional practice. Faculty development initiatives contribute to strengthening clinicians' approach to teaching. In order to inform the design of such initiatives, we thought that it would be useful to discover how senior medical students' experience of clinical teaching may impact on how learning during clinical training might be strengthened. METHODS: This qualitative study was conducted using convenience sampling of medical students in the final two months of study before qualifying. Three semi-structured focus group discussions were held with a total of 23 students. Transcripts were analysed from an interpretivist stance, looking for underlying meanings. The resultant themes revealed a tension between the students' expectations and experience of clinical teaching. We returned to our data looking for how students had responded to these tensions. RESULTS: Students saw clinical rotations as having the potential for them to apply their knowledge and test their procedural abilities in the environment where their professional practice and identity will develop. They expected engagement in the clinical workplace. However, their descriptions were of tensions between prior expectations and actual experiences in the environment. They appreciated that learning required them to move out of their "comfort zone", but seemed to persist in the idea of being recipients of teaching rather than becoming directors of their own learning. Students seem to need help in participating in the clinical setting, understanding how this participation will construct the knowledge and skills required as they join the workplace. Students did not have a strong sense of agency to negotiate participation in the clinical workplace. CONCLUSIONS: There is the potential for clinicians to assist students in adapting their way of learning from the largely structured classroom based learning of theoretical knowledge, to the more experiential informal workplace-based learning of practice. This suggests that faculty developers could broaden their menu of offerings to clinicians by intentionally incorporating ways not only of offering students affordances in the clinical learning environment, but also of attending to the development of students' agentic capability to engage with those affordances offered.

Medical Student Exposure to Cancer Patients Whilst on Clinical Placement: a Retrospective Analyses of Clinical Log Books.

In Australia, one in two men and one in three women will be diagnosed with cancer by the age of 85. Several studies have demonstrated a decline in the number of medical graduates having examined cancer patients during their training. The aim of this study was to evaluate the exposure of medical students to cancer patients during clinical placements. Eighty-eight logbooks (response rate = 24.75%) containing 9430 patients were analysed. A total of 829 patients (8.79%) had a diagnosis of cancer. Most cancer patients were seen on surgical placements, whilst general practice placements returned the lowest numbers. None were seen in paediatrics or ophthalmology. Given the role surgery plays in the staging and treatment of cancer, it is unsurprising that most cancer patients were seen during surgery.  Most concerning was the number of patients with common cancers seen by our students. Only 46% of students saw a patient with breast cancer. Even fewer saw patients with colorectal (41%), lung (32%) and prostate cancer (30%). Only 14% saw a melanoma patient. Variability in the quality of the logbooks is the main limitation of this study, and therefore, it is not a complete picture of cancer patient exposure. However, it builds upon previous studies by providing insight to the number and types of cancer patients to which students were exposed. Overall, the exposure to common cancers remains concerning and further research is needed to explore the type and quality of these interactions over the course of an entire year.

Students with an autonomous role in hospital care - patients perceptions.

BACKGROUND: There have been calls to enhance clinical education by strengthening supported active participation (SAP) of medical students in patient care. This study examines perceived quality of care when final-year medical students are integrated in hospital ward teams with an autonomous relationship toward their patients. METHODS: We established three clinical education wards (CEWs) where final-year medical students were acting as "physician under supervision". A questionnaire-based mixed-method study of discharged patients was completed in 2009-15 using the Picker Inpatient Questionnaire complemented by specific questions on the impact of SAP. Results were compared with matched pairs of the same clinical specialty from the same hospital (CG1) and from nationwide hospitals (CG2). Patients free-text feedback about their hospital stay was qualitatively evaluated. RESULTS: Of 1136 patients surveyed, 528 (46.2%) returned the questionnaire. The CEWs were highly recommended, with good overall quality of care and patient-physician/student-interaction, all being significantly (p < 0.001) higher for the CEW group while experienced medical treatment success was similar. Patient-centeredness of students was appreciated by patients as a support to a deeper understanding of their condition and treatment. CONCLUSION: Our study indicates that SAP of final-year medical students is appreciated by patients with high overall quality of care and patient-centeredness.