On pandemics and pivots: a COVID-19 reflection on envisioning the future of medical education.

The required adjustments precipitated by the coronavirus disease 2019 crisis have been challenging, but also represent a critical opportunity for the evolution and potential disruptive and constructive change of medical education. Given that the format of medical education is not fixed, but malleable and in fact must be adaptable to societal needs through ongoing reflexivity, we find ourselves in a potentially transformative learning phase for the field. An Association for Medical Education in Europe ASPIRE Academy group of 18 medical educators from seven countries was formed to consider this opportunity, and identified critical questions for collective reflection on current medical education practices and assumptions, with the attendant challenge to envision the future of medical education. This was achieved through online discussion as well as asynchronous collective reflections by group members. Four major themes and related conclusions arose from this conversation: Why we teach: the humanitarian mission of medicine should be reinforced; what we teach: disaster management, social accountability and embracing an environment of complexity and uncertainty should be the core; how we teach: open pathways to lean medical education and learning by developing learners embedded in a community context; and whom we teach: those willing to take professional responsibility. These collective reflections provide neither fully matured digests of the challenges of our field, nor comprehensive solutions; rather they are offered as a starting point for medical schools to consider as we seek to harness the learning opportunities stimulated by the pandemic.

Relationships Matter: Enhancing Trainee Development with a (Simple) Clerkship Curriculum Reform.

PROBLEM: The traditional clerkship model of brief encounters between faculty and students results in reduced meaningful learning opportunities due to the lack of a relationship that enables repeated observation, supervisor feedback, trust formation, and growth. INTERVENTION: Clinical clerkships at our institution were restructured to decrease fragmentation of supervision and foster an educational alliance between faculty and student. A mixed-methods approach was used to study the impact of this curriculum reform on the student experience in the obstetrics and gynecology clerkship. Student participation in patient care was assessed by comparing the number of common obstetric procedures performed before and after clerkship reform. Separate qualitative analyses of comments from student surveys and a faculty focus group revealed themes impacting student involvement. The supervisor-trainee relationship was further investigated by analysis of "rich picture" discussions with students and faculty. CONTEXT: Clerkships in the 3rd year of our 4-year undergraduate medical curriculum were converted from an experience fragmented by both didactic activities and multiple faculty supervisors to one with a single supervisor and the elimination of competing activities. OUTCOMES: Students in the revised clerkship performed twice the number of obstetric procedures. Objective measures (United States Medical Licensing Examination Step 1 scores, receiving clerkship honors, self-reported interest in obstetrics, and gender) did not correlate with the number of procedures performed by students. Qualitative analysis of student survey comments revealed that procedure numbers were influenced by being proactive, having a supervisor with a propensity to teach (trust), and contextual factors (busy service or competition with other learners). Themes identified by faculty that influenced student participation included relationship continuity; growth of patient care skills; and observed student engagement, interest, and confidence. The quality of the relationship was cited by both students and faculty as a factor influencing meaningful clinical participation. Discussions of "rich pictures" drawn by students and faculty revealed that relationships are influenced by continuity, early alignment of goals, and the engagement and attitude of both student and faculty. LESSONS LEARNED: Clinical curricular reforms that strengthen the continuity of the supervisor-trainee relationship promote mutual trust and can result in a more meaningful training experience in less time. Reciprocal engagement and early alignment of goals between supervisor and trainee are critical for creating a positive relationship.

Translation, Transcultural Adaptation, and Validation of the Empathy, Spirituality, and Wellness in Medicine Scale to the Brazilian Portuguese Language.

Construct: The Empathy, Spirituality, and Wellness in Medicine Scale (ESWIM) is a 43-item multidimensional scale developed to investigate different dimensions of physicians and medical students. Background: Medical education research requires the use of several different instruments with dozens of items that evaluate each construct separately, making their application slow and increasing the likelihood of students providing a large number of incomplete or missing responses. To provide an alternative measure, this study aims to translate, adapt, and validate the multidimensional ESWIM instrument for Brazilian medical students. This is a very promising instrument because it is multidimensional, relatively short, and cost free; it evaluates important constructs; and it has been explicitly designed for use in the medical context. Approach: The English-language instrument was translated and adapted into the Brazilian Portuguese language using standard procedures: translation, transcultural adaptation, and back-translation. ESWIM was administered to students in all years of the medical curriculum. A retest was given 45 days later to evaluate reliability. To assess validity, the questionnaire also included sociodemographic data, the Duke Religion Index, the Empathy Inventory, the brief version of the World Health Organization Quality of Life (WHOQOL-Bref), and the Oldenburg Burnout Inventory. Results: A total of 776 medical students (M age = 22.34 years, SD = 3.11) were assessed. The Brazilian Portuguese version of ESWIM showed good internal consistency for the factor of Empathy (α = 0.79-0.81) and borderline internal consistency for the other factors: Openness to Spirituality (α = 0.61-0.66), Wellness (α = 0.57-0.68), and Tolerance (α = 0.56-0.65). The principal component analysis revealed a four-factor structure; however, the confirmatory factor analysis showed a better fit for a three-factor structure. We found a significant positive correlation between ESWIM empathy and empathy measured by the Empathy Inventory (r = .444, p < .01), as well as negative correlations between ESWIM empathy and burnout (r = -.145 to -.224, p < .01). ESWIM openness to spirituality was also significantly correlated with different subscales of religiosity (r = .301-.417, p < .01), and ESWIM wellness was significantly correlated with the WHOQOL-Bref factors (r = .390-.673, p < .01). The test-retest reliability (applied to 83 students) was high for all factors except Tolerance. Conclusion: This study provides supportive evidence regarding the reliability and validity of ESWIM empathy scores. The ESWIM scale opens a new field of research in relation to openness to spirituality by introducing a scale that measures this openness attitude. Despite borderline internal consistency, ESWIM wellness was strongly associated with quality of life and had good test-retest reliability. Thus, ESWIM appears to be a valid option for evaluating these constructs in medical students.

Empathy in Medical Students Is Moderated by Openness to Spirituality.

THEORY: Empathy is one component of medical student education that may be important to nurture, but there are many potential psychological barriers to empathy, such as student depression, burnout, and low quality of life or wellness behaviors. However, few studies have addressed how positive behaviors such as wellness and spirituality, in combination with these barriers, might affect empathy. HYPOTHESES: We hypothesized a negative relationship between psychological distress and empathy, and a positive relationship between empathy and wellness behaviors. We also hypothesized that openness to others' spirituality would moderate the effects of psychological distress on empathy in medical students. METHOD: This cross-sectional study included 106 medical students in a public medical school in the U.S. Midwest. Mailed questionnaires collected student information on specialty choice and sociodemographics, empathy, spirituality openness, religiosity, wellness, burnout, depression, anxiety, and stress. Hierarchical multiple regression analysis was conducted, with empathy as the dependent variable, psychological distress and all wellness behaviors as predictors, and spirituality openness as a moderator. RESULTS: Specialty choice, burnout, wellness behaviors, spirituality openness, and religiosity were significant independent predictors of empathy. In addition, when added singly, one interaction was significant: Spirituality Openness × Depression. Spirituality openness was related to empathy only in nondepressed students. Empathy of students with higher levels of depression was generally lower and not affected by spirituality openness. CONCLUSIONS: Nondepressed students who reported lower openness to spirituality might benefit most from empathy training, because these students reported the lowest empathy. Highly depressed or disengaged students may require interventions before empathy can be addressed. In addition, burnout was related to lower levels of empathy and wellness was related to higher levels. These provide potential points of intervention for medical schools developing tools to increase medical trainees' empathy levels.

Feedback matters: the impact of an intervention by the dean on unprofessional faculty at one medical school.

PURPOSE: Unprofessional behavior by faculty can result in poor patient care, poor role modeling, and mistreatment of trainees. To improve faculty or institutional behavior, unprofessional faculty must be given direct feedback. The authors sought to determine whether annually surveying medical students for their nominations of most and least professional faculty, coupled with direct feedback to unprofessional faculty from the dean, improved faculty's professional behavior. METHOD: From 2007 to 2012, senior medical students at Southern Illinois University School of Medicine completed an anonymous survey naming the "most professional" and "least professional" faculty in each department. Students described unprofessional behaviors, and their descriptions were qualitatively analyzed. The most unprofessional faculty met with the dean to discuss their behavior. The authors examined differences between faculty named most professional in their department versus those named least professional and whether behavior as measured by student nominations changed following feedback. RESULTS: The response rate overall for six graduating classes was 92.5% (385/416). Faculty named most professional were highly associated with receiving teaching and humanism awards. Faculty named most unprofessional were shown to either leave the institution or improve their behavior after receiving feedback. CONCLUSIONS: Attitudes and behaviors of teachers create the culture of their institution, and unprofessional behavior by these educators can have a profound, negative effect. Direct involvement by the dean may be an effective tool to improve the learning environment of a single institution, but universal application of such a program is needed if the profession as a whole is to improve its culture.

Unprofessional behavior by specialty: a qualitative analysis of six years of student perceptions of medical school faculty.

BACKGROUND: Unprofessional behavior has well documented negative effects both on the clinical care environment and on the learning environment. If unprofessional behavior varies by department or specialty, this has implications both for faculty development and for undergraduate and graduate level training. AIMS: We sought to learn which unprofessional behaviors were endemic in our school, and which were unique to particular departments. METHODS: Students graduating from medical school between 2007 and 2012 were asked to complete a questionnaire naming the most professional and least professional faculty members they encountered in during school. For the least professional faculty members, they were also asked to provide information about the unprofessional behavior. RESULTS: Students noted several types of unprofessional behavior regardless of the department faculty were in; however, there were some behaviors only noted in individual departments. The unprofessional behavior profiles for Surgery and Obstetrics/Gynecology were markedly similar, and were substantially different from all other specialties. CONCLUSION: Undergraduate, graduate, and faculty education focused on unprofessional behavior that may occur in various learning environments may provide a feasible, practical, and an effective approach to creating a culture of professional behavior throughout the organization.

Do racial and ethnic group differences in performance on the MCAT exam reflect test bias?

The Medical College Admission Test (MCAT) is a standardized examination that assesses fundamental knowledge of scientific concepts, critical reasoning ability, and written communication skills. Medical school admission officers use MCAT scores, along with other measures of academic preparation and personal attributes, to select the applicants they consider the most likely to succeed in medical school. In 2008-2011, the committee charged with conducting a comprehensive review of the MCAT exam examined four issues: (1) whether racial and ethnic groups differ in mean MCAT scores, (2) whether any score differences are due to test bias, (3) how group differences may be explained, and (4) whether the MCAT exam is a barrier to medical school admission for black or Latino applicants. This analysis showed that black and Latino examinees' mean MCAT scores are lower than white examinees', mirroring differences on other standardized admission tests and in the average undergraduate grades of medical school applicants. However, there was no evidence that the MCAT exam is biased against black and Latino applicants as determined by their subsequent performance on selected medical school performance indicators. Among other factors which could contribute to mean differences in MCAT performance, whites, blacks, and Latinos interested in medicine differ with respect to parents' education and income. Admission data indicate that admission committees accept majority and minority applicants at similar rates, which suggests that medical students are selected on the basis of a combination of attributes and competencies rather than on MCAT scores alone.

Reports of the decline of empathy during medical education are greatly exaggerated: a reexamination of the research.

PURPOSE: Research is said to show that empathy declines during medical school and residency training. These studies and their results were examined to determine the extent of the decline and the plausibility of any alternative explanations. METHOD: Eleven studies published from 2000 to 2008 which reported empathy at various stages of physician training were reexamined. Their results were transformed back to the original units of the rating scales to make results more interpretable by reporting them in the metric of the original anchors. Next, the relationship between empathy ratings and response rates were examined to see whether response bias was a plausible threat to the validity of the empathy decline conclusion. RESULTS: The changes in mean empathy ranged across the 11 studies from a 0.1-point increase in empathy to a 0.5-point decrease, with an average of a 0.2-point decline for the 11 studies (ratings were on 5-point, 7-point, and 9-point scales). Mean ratings were similar in medical school and residency. Response rates were low and-where reported-declined on average about 26 percentage points. CONCLUSIONS: Reexamination revealed that the evidence does not warrant the strong, disturbing conclusion that empathy declines during medical education. Results show a very weak decline in mean ratings, and even the weak decline is questionable because of the low and varying response rates. Moreover, the empathy instruments are self-reports, and it isn't clear what they measure-or whether what they measure is indicative of patients' perceptions and the effectiveness of patient care.

Prevalence of health-related behaviors among physicians and medical trainees.

OBJECTIVE: The authors studied the prevalence of health-promoting and health-risking behaviors among physicians and physicians-in-training. Given the significant potential for negative outcomes to physicians' own health as well as the health and safety of their patients, examination of the natural history of this acculturation process about physician self-care and wellness is critical to the improvement of the western health care delivery system. METHODS: 963 matriculating medical students, residents, or attending physicians completed the Empathy, Spirituality, and Wellness in Medicine (ESWIM) survey between the years 2000 and 2004. Items specific to physician wellness were analyzed. These included healthy behaviors as well as risk behaviors. RESULTS: Both medical students and attending physicians scored higher in overall wellness than did residents. Residents were the lowest scoring group for getting enough sleep, using seatbelts, and exercising. Medical students were more likely to smoke tobacco and drink alcohol. Medical students reported less depression and anxiety and more social contacts. CONCLUSION: Medical school training may prevent students from maintaining healthy behaviors, so that by the time they are residents they exercise less, sleep less, and spend less time in organizational activities outside of medical school. If physicians do not engage in these healthy behaviors, they are less likely to encourage such behaviors in their patients and patients are less likely to listen to them even if they do talk about it.

Using indirect questions to detect intimate partner violence: the SAFE-T questionnaire.

A screening instrument for detecting intimate partner violence (IPV) was developed using indirect questions. The authors identified 5 of 18 items studied that clearly distinguished victims of IPV from a random group of health conference attendees with a sensitivity of 85% and a specificity of 87%. This 5-item instrument (SAFE-T) was then tested on 435 women presenting to three emergency departments and the results compared to a direct question regarding current abuse. The SAFE-T questions detected only 54% of the women who admitted being abused and correctly classified 81% of the women who said they were not victims. The 1-year prevalence of IPV in this sample of women presenting to an emergency department was 11.6%. The authors conclude that indirect questioning of women appears to be more effective at ruling out IPV in an emergency department population and may be less useful for women "early" in an abusive relationship.

Effect of gender, age, and relevant course work on attitudes toward empathy, patient spirituality, and physician wellness.

BACKGROUND: The emphasis in medical education on viewing the patient as a whole person addresses current concerns about the negative impact of standard physician training that may lead to impaired patient-physician relationships. PURPOSES: To assess self-ratings of empathy, spirituality, wellness, and tolerance in a sample of medical students and practitioners to explore differences by gender, age, and training. METHODS: A survey was created that assesses empathy, spirituality, wellness, and tolerance in the medical setting. Surveys were completed anonymously by medical students and practitioners from the medical school. RESULTS: The youngest groups scored highest on empathy and wellness and lowest on tolerance. Participation in medical school wellness sessions correlated with higher empathy and wellness scores; participation in both empathy and spirituality sessions correlated with higher empathy scores. CONCLUSION: Exposure to educational activities in empathy, philosophical values and meaning, and wellness during medical school may increase empathy and wellness in medical practice.

Risk-factor fusion for predicting multifactorial diseases.

A generalized classification methodology is developed to predict the presence or absence of a multifactorial disease from a set of risk factors thought to be correlated with the disease. The methodology includes fusion to combine risk factors into a single feature vector, normalization to overcome the problems associated with fusing features which have different formats and ranges, discrete Karhunen-Loeve transform (DKLT)-based transformation to facilitate parametric classifier development, the selection of features with high interclass separations, and the design of parametric classifiers. The validity of the method is demonstrated by applying it to predict the occurrence of gout from 14 risk factors. Cross-validation evaluations on 96 patients, 48 clinically diagnosed to have gout and 48 diagnosed to not have gout, showed that an average classification accuracy of 75.7% can be obtained. Even more promising is that higher classification accuracies can be achieved through the careful selection of the DKLT transformation matrix which in turn involves selecting design sets that are good representatives of the gout and nongout classes. It is concluded that the generalized methodology developed in this paper is quite effective in predicting multifactorial diseases and can, therefore, assist/support a physician in diagnosing a multifactorial disease.