Medical Student Perceptions of the Learning Environment in Medical School Change as Students Transition to Clinical Training in Undergraduate Medical School.

Phenomenon: The learning environment is the physical, social, and psychological context in which a student learns. A supportive learning environment contributes to student well-being and enhances student empathy, professionalism, and academic success, whereas an unsupportive learning environment may lead to burnout, exhaustion, and cynicism. Student perceptions of the medical school learning environment may change over time and be associated with students' year of training and may differ significantly depending on the student's gender or race/ethnicity. Understanding the changes in perceptions of the learning environment related to student characteristics and year of training could inform interventions that facilitate positive experiences in undergraduate medical education. APPROACH: The Medical School Learning Environment Survey (MSLES) was administered to 4,262 students who matriculated at one of 23 U.S. and Canadian medical schools in 2010 and 2011. Students completed the survey at the end of each year of medical school as part of a battery of surveys in the Learning Environment Study. A mixed-effects longitudinal model, t tests, Cohen's d effect size, and analysis of variance assessed the relationship between MSLES score, year of training, and demographic variables. FINDINGS: After controlling for gender, race/ethnicity, and school, students reported worsening perceptions toward the medical school learning environment, with the worst perceptions in the 3rd year of medical school as students begin their clinical experiences, and some recovery in the 4th year after Match Day. The drop in MSLES scores associated with the transition to the clinical learning environment (-0.26 point drop in addition to yearly change, effect size = 0.52, p < .0001) is more than 3 times greater than the drop between the 1st and 2nd year (0.07 points, effect size = 0.14, p < .0001). The largest declines were from items related to work-life balance and informal student relationships. There was some, but not complete, recovery in perceptions of the medical school learning environment in the 4th year. Insights: Perceptions of the medical school learning environment worsen as students continue through medical school, with a stronger decline in perception scores as students' transition to the clinical learning environment. Students reported the greatest drop in finding time for outside activities and students helping one another in the 3rd year. Perceptions differed based on gender and race/ethnicity. Future studies should investigate the specific features of medical schools that contribute most significantly to student perceptions of the medical school learning environment, both positive and negative, to pinpoint potential interventions and improvements.

A comparison of medical students' learning approaches between the first and fourth years.

OBJECTIVES: We hypothesized that medical students exposed to a case-based curriculum in years 1 and 2 and clinical cases in the year 3 clerkship would demonstrate a longitudinal increase in the deep approach to learning and a decrease in the surface apathetic approach. METHODS: A cohort of first-year medical students completed the Approaches and Study Skills Inventory for Students at the beginning of their first term and again at the beginning of their fourth year. Approaches and Study Skills Inventory for Students scores were aggregated into three main learning approach scales: deep, strategic, and surface apathetic. RESULTS: On average, deep and strategic scores did not significantly change between years 1 and 4, but the surface apathetic mean score decreased as a result of lower syllabus boundness and fear of failure subscale scores. Effect sizes were small (d = 0.30, 0.34, respectively). CONCLUSIONS: The deep approach to learning is a complex process and did not change in our students after 3 years of medical school, even though a case-based curriculum was believed to foster deeper learning. By the end of year 3, our students were, on average, less bound to syllabi and feared failure less.

Health Justice and Systems of Care: A Required Longitudinal Course for MD Students.

Problem & Background: Medical education has acknowledged the impact of structural societal factors on health, prompting the need for curricula seeking to eliminate health inequities upstream while simultaneously caring for downstream effects of existing inequities. The Keck School of Medicine of USC (KSOM) implemented one such comprehensive curriculum, Health Justice and Systems of Care (HJSC), integrating health systems science, structural competency, and service-learning in a required course spanning the pre-clerkship and clerkship phases with an optional post clerkship elective. Approach: The HJSC course addresses topics including racism in medicine, health inequities, and health systems science. Using transformative learning theory, it fosters critical consciousness and structural competency. Assessments include case analyses, reflections, team-based learning sessions, and group projects related to social justice in healthcare. The program aims to instill cultural humility and practical application, fostering a holistic approach to medical education that implores physicians to become advocates for health justice. Outcomes of the Innovation: Feedback from students indicated generally positive perceptions of the curriculum. Students provided overall positive comments about discussions with guest speakers. However, students expressed a desire for more concrete examples of how health inequities can be remedied. Some found small-group activities less engaging. Other challenges included providing students of different readiness levels with tailored experiences and seamlessly integrating HJSC content within basic and clinical sciences courses. Critical Reflection: Next steps include continuing to integrate content into the science curriculum and clerkships, improving opportunities for meaningful student interactions, and enhancing faculty development to address health justice concerns in clinical settings.

The relationship between medical students' learning approaches and performance on a summative high-stakes clinical performance examination.

BACKGROUND: A learning approach embeds the intention of the student when starting a task and the learning processes and strategies used to carry out a task. Student approaches to learning have been categorized as deep, strategic, and surface. AIM: To explore the relationships among medical students' learning approaches, gender, and performance on a summative high-stakes clinical performance examination (CPX). METHODS: We measured medical students' learning approaches at the beginning of year four using the Approaches and Study Skills Inventory for Students and compared results with CPX scores. RESULTS: Student scores in the top two quartiles of the CPX were significantly higher on the deep approach than student CPX scores in the bottom quartile, and student scores in the bottom quartile of the CPX were significantly higher on the surface approach than scores for the other three CPX quartiles. CPX patient-physician interaction scores showed a significant positive correlation with deep approach scores, and CPX overall patient satisfaction scores showed a significant positive correlation with deep and strategic approach scores. Surface approach scores correlated negatively with all CPX score categories. CONCLUSION: Approach to learning was associated with performance on a high-stakes CPX.

Adults' Reaction to Public Health Messaging: Recall, Media Type, and Behavior Change Motivation.

This paper focuses on effective messaging practices identified in data collected after 10 years of implementing a gain-framed messaging campaign encouraging healthier behaviors in middle-aged and older adults. In Study 1, we measured message recall and intended health behaviors in an intercept survey of 733 adults. Binary logistic regression indicated that women were more likely than men to report intent to change behavior. Recalling messages from billboards or fliers was associated with a lower likelihood of intended behavior change, and media type was associated with intended behavior for those who saw the message online (reducing screen time) or on television (increasing physical activity and ceasing smoking). Study 2 focused on adult generational differences in response to the campaign and types of media used to access information. Data from an intercept survey of 604 clients at agencies serving low-income adults were segmented into three age groups: under 35, ages 35-54, and ages 55+. Recall and reaction to campaign materials differed by age group, and the influence of life stage factors and health costs varied across age groups. Television and newspapers were most frequently reported by the oldest group, and social media and online news/blogs were most frequently chosen by the youngest group. Campaign response of adults older than age 35 aligned with goals of improving health behaviors. Together, these studies indicate that diffuse messaging strategies may raise overall awareness, and targeted strategies may be more influential in motivating behavior change. Influential factors and media should be differentially leveraged to target different age cohorts of adults.

Preparing Effective Narrative Evaluations for the Medical School Performance Evaluation (MSPE).

Introduction: In 2016, the AAMC Medical School Performance Evaluation (MSPE) Task Force issued recommendations to standardize the MSPE but did not address the quality of the written narratives in that document. Narrative evaluations are hampered by code words, polite rhetoric, and bias to the detriment of students. To address this, the AAMC's Group on Student Affairs and Group on Educational Affairs convened an expert group to consider the state of narratives in the MSPE and develop resources to improve their quality. Methods: A series of interactive workshops was developed and presented at an AAMC webinar and national meetings. A presentation outlining challenges and possible approaches to improvement was followed with large-group discussion and/or small-group breakout activity to analyze and improve upon sample clinical comments and create summary clerkship paragraphs. The initial webinar used polling questions and free-text prompts to gather feedback for future workshops. Anonymous survey responses were collected at the end of each subsequent workshop to determine perceived effectiveness and potential utility at participants' institutions. Results: Over 680 administrators, faculty, and staff participated in the webinar or in one of four national-level workshops. Respondents agreed that the modules would be useful in faculty development and wanted to replicate their learning at their own institutions for overall better impact on the quality of MSPE narratives. Discussion: This resource addresses an important gap in the medical education literature. A variety of stakeholders affirmed that these workshops have value in training writers to improve their narrative comments for the MSPE.

Assessing patient-centered care: one approach to health disparities education.

BACKGROUND: Patient-centered care has been described as one approach to cultural competency education that could reduce racial and ethnic health disparities by preparing providers to deliver care that is respectful and responsive to the preferences of each patient. In order to evaluate the effectiveness of a curriculum in teaching patient-centered care (PCC) behaviors to medical students, we drew on the work of Kleinman, Eisenberg, and Good to develop a scale that could be embedded across cases in an objective structured clinical examination (OSCE). OBJECTIVE: To compare the reliability, validity, and feasibility of an embedded patient-centered care scale with the use of a single culturally challenging case in measuring students' use of PCC behaviors as part of a comprehensive OSCE. METHODS: A total of 322 students from two California medical schools participated in the OSCE as beginning seniors. Cronbach's alpha was used to assess the internal consistency of each approach. Construct validity was addressed by establishing convergent and divergent validity using the cultural challenge case total score and OSCE component scores. Feasibility assessment considered cost and training needs for the standardized patients (SPs). RESULTS: Medical students demonstrated a moderate level of patient-centered skill (mean = 63%, SD = 11%). The PCC Scale demonstrated an acceptable level of internal consistency (alpha = 0.68) over the single case scale (alpha = 0.60). Both convergent and divergent validities were established through low to moderate correlation coefficients. DISCUSSION: The insertion of PCC items across multiple cases in a comprehensive OSCE can provide a reliable estimate of students' use of PCC behaviors without incurring extra costs associated with implementing a special cross-cultural OSCE. This approach is particularly feasible when an OSCE is already part of the standard assessment of clinical skills. Reliability may be increased with an additional investment in SP training.

Evaluation of a feasibility study addressing risk factors for childhood obesity through home visits.

AIM: This pilot study aimed to explore the feasibility of addressing risk factors for childhood obesity through a home-based early intervention program. METHOD: A pilot study was conducted with 56 first-time mothers, recruited through the antenatal and delivery units of an inner western Sydney hospital. The study offered five home visits by a community early childhood health nurse during the child's first year of life. At each visit, the intervention was tailored to the appropriate developmental stage of the child. One-to-one consultation was provided with a focus on sustained breastfeeding, appropriate introduction of solids, avoiding food rewards and promoting the drinking of water and the use of a cup. Both quantitative and qualitative methods were applied to assess the feasibility and acceptability of the program. RESULTS: The results indicate that the program was very well received by the participating mothers, with a retention rate of 95%. Compared with the state population average, the rate of breastfeeding at 12 months was significantly higher (36% vs. 18%, chi(2)= 8.21, P < 0.01), there was a lower rate of the introduction of solids before 4 months (2% vs. 13%, chi(2)= 8.73, P < 0.01), and there was a high rate of cup usage at 12 months (98%). CONCLUSIONS: The early onset of childhood overweight and obesity requires health promotion intervention programs to commence as early as possible. A home-based intervention through multiple home visits is feasible in addressing the risk factors for childhood obesity.

Shaping professionalism in pre-clinical medical students: Professionalism and the practice of medicine.

BACKGROUND: Increasing emphasis is placed on teaching and assessment of professionalism in the continuum of medical education. Consistent and longitudinal instruction and assessment are crucial factors that learners need in order to internalize the tenets of professionalism. AIM: We aimed to develop a novel longitudinal course in professionalism spanning the first 2 years in a medical curriculum. METHODS: This is a description of the process undertaken over the past 7 years to develop and implement a professionalism curriculum. We used the conceptual framework of constructivism, principles of adult learning, experiential learning and reflective practice to integrate learning with experience. We included student input in session development. Faculty mentors serve as role models to guide, assist and counsel students. Assessment of learners is accomplished using self, peer and mentor evaluation, and a student portfolio. Program evaluation is by course and faculty evaluation. RESULTS: Students are given a final grade of pass or fail, together with a brief narrative. Course evaluations were positive. A survey questionnaire showed that more than 60% of the students reported gaining skills related to course goals. CONCLUSIONS: A longitudinal curriculum for the pre-clinical years was successfully launched. Plans are under way to expand this into the clinical years.

A Continuum of Innovation: Curricular Renewal Strategies in Undergraduate Medical Education, 2010-2018.

PURPOSE: Since 2010, medical schools across the United States have engaged in a new cycle of curricular revision and renewal for their undergraduate medical curricula. But what structures, features, and trends have emerged in U.S. medical schools as a result of deliberate curricular redesign efforts? An analysis of the ways that medical schools have approached the reorganization of their curricula to prepare their students for the growing complexity of medical practice is presented. METHOD: This study drew a total pool of 40 U.S. MD-granting programs, of which 25 met the inclusion criteria for the study. The authors used a qualitative coding approach to materials from the undergraduate medical education (UME) program websites to identify 4 dimensions of strategies that these programs used to renew their curricula. RESULTS: The analysis of the curricular maps and website content of the UME programs provided evidence for a continuum approach to the description of innovation strategies: 96% of schools employed a cohort-based linear pathway, 80% of schools used thematic basic science blocks, 47% placed their Step 1 exams outside of the second year, and 68% moved their clerkships to the second year. CONCLUSIONS: The Continuum of Innovation strategies will enable programs to renew their curricula in ways that promote deliberate curricular changes that are consistent with emerging needs in the field. This study and future research may be useful for UME programs with limited resources by providing consensus practices that enable them to plan curricular changes in ways that best serve their institutions.

Effect of adrenergic stimulation on action potential duration restitution in humans.

BACKGROUND: Enhanced sympathetic activity facilitates complex ventricular arrhythmias and fibrillation. The restitution properties of action potential duration (APD) are important determinants of electrical stability in the myocardium. Steepening of the slope of APD restitution has been shown to promote wave break and ventricular fibrillation. The effect of adrenergic stimulation on APD restitution in humans is unknown. METHODS AND RESULTS: Monophasic action potentials were recorded from the right ventricular septum in 18 patients. Standard APD restitution curves were constructed at 3 basic drive cycle lengths (CLs) of 600, 500, and 400 ms under resting conditions and during infusion of isoprenaline (15 patients) or adrenaline (3 patients). The maximum slope of the restitution curves was measured by piecewise linear regression segments of sequential 40-ms ranges of diastolic intervals in steps of 10 ms. Under control conditions, the maximum slope was steeper at longer basic CLs; eg, mean values for the maximum slope were 1.053+/-0.092 at CL 600 ms and 0.711+/-0.049 at CL 400 ms (+/-SEM). Isoprenaline increased the steepness of the maximum slope of APD restitution, eg, from a maximum slope of 0.923+/-0.058 to a maximum slope of 1.202+/-0.121 at CL 500 ms. The effect of isoprenaline was greater at the shorter basic CLs. A similar overall effect was observed with adrenaline. CONCLUSIONS: The adrenergic agonists isoprenaline and adrenaline increased the steepness of the slope of the APD restitution curve in humans over a wide range of diastolic intervals. These results may relate to the known effects of adrenergic stimulation in facilitating ventricular fibrillation.

"Being the best we can be": medical students' reflections on physician responsibility in the social media era.

PURPOSE: To examine attitudes, self-reported behaviors, and intended actions related to medical students' use of online social media after an educational intervention. METHOD: In 2011, 180 first-year medical students at the Keck School of Medicine participated in a required two-hour session on the relevance of online social media use to professionalism. Students submitted postsession written reflections about their online presence and professional roles. The authors qualitatively analyzed and coded these reflections for emerging themes. They also examined postsession evaluations and conducted a four-month follow-up survey to identify changes in students' online social networking behaviors. RESULTS: All 180 students submitted written reflections and postsession evaluations. The authors identified 10 theme categories within three domains (immediate action, intended future action, value change) from the reflections. The most common themes were "role awareness" (144/539), "did nothing" (94/539), and "intention to edit" (84/539). On a scale of 1 to 5, students rated the overall session quality at 3.92 (standard deviation 0.28). Sixty-four percent (115/180) of the students responded to the follow-up survey. Of those, 40% (46/115) reported editing or changing their Web presence after the session, and 24% (28/115) anticipated spending less time on online social networking. CONCLUSIONS: Attending a required session in a professionalism course led to thoughtful reflection, increased professional role awareness, and intention to edit and monitor future online presence among first-year medical students. After four months, students reported continued monitoring and editing of their online presence. Future studies should examine whether reinforcement throughout training is needed to maintain vigilance.

Effect of educational interventions and medical school policies on medical students' attitudes toward pharmaceutical marketing practices: a multi-institutional study.

PURPOSE: To determine the effect of educational interventions on medical students' attitudes toward pharmaceutical industry marketing practices and whether restrictive medical school policies governing medicine-industry interactions are associated with student support for banning such interactions. METHOD: Prospective cohort study involving the graduating classes of 2009 (intervention, n=474) and 2010 (control, n=459) at four U.S. medical schools. Intervention students experienced a former pharmaceutical representative's presentation, faculty debate, and a Web-based course. Both groups completed baseline and follow-up attitude surveys about pharmaceutical marketing. RESULTS: A total of 482 students (51.6%) completed both surveys. In regression analyses, intervention students were more likely than control students to think that physicians are strongly or moderately influenced by pharmaceutical marketing (OR, 2.29; 95% CI, 1.46-3.59) and believed they would be more likely to prescribe a company's drug if they accepted that company's gifts and food (OR, 1.68; 95% CI, 1.12-2.52). Intervention students were more likely to support banning interactions between pharmaceutical representatives and students (OR, 4.82; 95% CI, 3.02-7.68) and with physicians (OR, 6.88; 95% CI, 4.04-11.70). Students from schools with more restrictive policies were more likely to support banning interactions between pharmaceutical representatives and students (OR, 1.99; 95% CI, 1.26-3.16) and with physicians (OR, 3.44; 95% CI, 2.05-5.79). CONCLUSIONS: Education about pharmaceutical marketing practices and more restrictive policies governing medicine-industry interactions seem to increase medical students' skepticism about the appropriateness of such marketing practices and disapproval of pharmaceutical representatives in the learning environment.

The development of a comprehensive school-wide simulation-based procedural skills curriculum for medical students.

OBJECTIVE: The purpose of this project was to assess the effectiveness of using the Delphi process to create a structured simulation-based procedural skills curriculum for all students at the Keck School of Medicine of the University of Southern California (KSOM). METHODS: The Delphi process was used to develop a list of procedural skills that students are expected to perform competently prior to graduation. Once consensus of faculty was reached, a needs assessment was performed to poll graduating seniors' experience performing each skill. A comprehensive simulation-based curriculum was developed and implemented for all Year II students at KSOM. Student satisfaction with the curriculum was collected using a standardized end-of-session evaluation form and student self confidence was assessed using a retrospective pre- and post-self-efficacy rating for each skill. RESULTS: The needs assessment clearly established the need for a more organized approach to teaching procedural skills at KSOM. Quantitative and qualitative data revealed that students responded favorably to the curriculum and appreciated the efforts put forth by KSOM. Student self-efficacy increased significantly for each skill. CONCLUSIONS: The Delphi process was effective in reaching consensus among educational leaders at KSOM regarding which skills to include in the curriculum. Although there were a few minor challenges, we determined that it is feasible to develop and implement an explicit school-wide simulated-based procedural skills curriculum.

Revising the Tool for Assessing Cultural Competence Training (TACCT) for curriculum evaluation: Findings derived from seven US schools and expert consensus.

BACKGROUND: The 67-item TACCT currently used for needs assessment has potential for evaluating evolving cultural competence (CC) curricula. PURPOSE: To validate a shortened, more practical TACCT measure. METHODS: The 67-item TACCT was administered to students and course directors at 7 US schools. Course directors and students reported which of 67 TACCT items were taught. Intraclass correlation coefficients (ICC) examined faculty-student agreement. Under-addressed content was identified. A new and shortened TACCT configuration was proposed and validated with expert educator input. RESULTS: Across-school faculty and student response rates ranged from 75% to 100%. Aggregate ICC was 0.90 (95% CI: 0.84, 0.94) for the 67-item TACCT demonstrating faculty-student agreement. Experts agreed on reduction from 67 to 42 items and domain revision from five to six domains to match under-addressed content. Item analysis showed high internal consistency for all 6 new domains and the total revised 42-item TACCT. CONCLUSIONS: A shorter, more practical TACCT measure is valid and reliable and focuses on under-addressed CC content. Use for curricular evaluation is suggested.

The nonphysician "medical student educator": a formal addition to the clerkships and key programs at an academic medical center.

BACKGROUND: Medical school faculty members face increased clinical and academic demands, leaving less time for teaching, curriculum development, and assessment of learners. DESCRIPTION: The Keck School of Medicine has hired a dedicated medical student educator for each required clerkship. The medical student educator assists the clerkship director with clinical teaching, curriculum development, student and program evaluation, and administrative functions. EVALUATION: The program has been well received by both students and faculty. Students believe that the medical student educators add value to their clinical experiences and support both their clinical education and personal and professional development. Preliminary data suggest that student performance has improved, and additional measures of quantitative impact are under way. CONCLUSIONS: Medical student educators have been a successful addition to the program at the Keck School of Medicine. This strategy should be considered at medical schools that are experiencing resource constraints.