Expanding Medical Education to Include Substance Use Disorders During Pregnancy and Postpartum: Preliminary Effectiveness of a Pilot Curriculum for Medical Students.

OBJECTIVE: To effectively combat the simultaneous overdose and maternal mortality crises, a multimodal approach is needed. The aim of this study is to evaluate the preliminary effectiveness of a pilot, experiential learning, substance use disorder (SUD) curriculum embedded into a third-year medical student obstetrics and gynecology clerkship to improve self-reported confidence in SUD clinical skills. METHODS: This SUD curriculum was designed and implemented in an outpatient clinic, which provides integrated obstetric, gynecologic, and addiction medicine services for pregnant and parenting people with SUD. Third-year medical students on their obstetrics and gynecology clerkship rotated 1 full day through the OB MOTIVATE clinic between August 2020 and April 2022 and completed this curriculum. Students completed preclinic assignments and in-clinic tasks (eg, practicing SBIRT under supervision: screening, brief intervention, referral to treatment). Paired t tests assessed changes in outcomes, with increasing scores (range 1-5) demonstrating improvement. RESULTS: Sixty-three students rotated through the OB MOTIVATE clinic; 57 completed the curriculum and surveys. Results from the self-assessment tools demonstrated significant improvements in confidence in SUD clinical skills, including performing SBIRT (2.46 ± 0.80 vs 4.07 ± 0.59, P < 0.01), motivational interviewing (2.98 ± 0.86 vs 4.16 ± 0.65, P < 0.01), using evidence-based medicine (2.91 ± 1.09 vs 4.23 ± 0.66, P < 0.01), and collecting an SUD history (3.25 ± 1.04 vs 4.35 ± 0.55, P = 0.01). CONCLUSIONS: The integration of interventional curriculums into medical school and residency programs could be an effective avenue to reinforce addiction knowledge and teach new skills. This practical 1-day pilot curriculum demonstrated preliminary effectiveness at introducing third-year medical students to the complexities of SUD in pregnancy and postpartum. Further investigations of feasible and acceptable SUD educational interventions are warranted.

Motivational Interviewing Education in North American Family Medicine Clerkships: A CERA Study.

BACKGROUND AND OBJECTIVES: Many health conditions are preventable or modifiable through behavioral changes. Motivational interviewing (MI) is an evidence-based communication technique that explores a patient's reasons for behavioral changes. This study assesses the current landscape of MI training in North American Family Medicine (FM) clerkships. METHODS: We analyzed data gathered as part of the 2022 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey of FM clerkship directors (CDs). The survey was distributed via email invitation to 159 US and Canadian FM CDs in June 2022. RESULTS: Of the 94 responses received, 61% indicated that MI training is provided in their FM clerkship. Medical school type, class size, and location were associated with MI training priority, offerings, and duration in the clerkship, respectively. CD experience correlated with MI training duration; student MI skill training level was associated with MI training duration and priority; the rigor of student MI skills evaluation was correlated with MI teaching methods and training duration; self-reported student MI competency was associated with the length of time students spent with FM community preceptors as well as MI training priority and teaching methods; and several items emerged as predictors of student, CD, and FM faculty MI training expansion. CONCLUSIONS: Opportunities exist to enhance the volume, content, and rigor of MI training in North American FM clerkships as well as to improve self-reported student MI competency within those clerkships.

Adapting Compassionate Conversations for Virtual Mediated Communication.

OBJECTIVE: The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. DESIGN: The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. SETTING: Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. PARTICIPANTS: Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. RESULTS: A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. CONCLUSIONS: This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

Understanding Academic Self-Concept and Performance in Medical Education.

PROBLEM: Medical students' academic self-concept (ASC) is an important factor in better understanding noncognitive mediators of performance in medical school. However, research is limited on ASC in medical students across multiple phases of undergraduate medical education curriculum. This pilot study explored the relationship between ASC and academic performance across different phases of a U.S. medical school curriculum, specifically at the end of the second (preclinical) and third (clinical) years. APPROACH: Medical students across 2 cohorts at Virginia Commonwealth University School of Medicine, Richmond, Virginia, were surveyed using an ASC confidence subscale in 2019. Multiple linear regression analysis was conducted using medical student ASC scores in preclinical (n = 190) and clinical (n = 149) phases and performance data. Clinical performance was calculated through a weighted mean of clerkship grades based on the number of weeks for each clerkship. OUTCOMES: Preclinical performance was related to ASC, gender, and performance after year 1. ASC scores varied significantly by gender in the preclinical cohort ( P < .01), with men reporting higher ASC than women (mean [SD], 2.94 [0.41] vs 2.78 [0.38]). Significant gender differences in performance were found at the end of year 3 ( P < .01), with women performing more favorably compared with men (mean [SD], 94.1 [59.04] vs 124.24 [64.54]). The relationship between ASC and performance at the end of year 2 suggested students with higher ASC perform better during their preclinical phase. NEXT STEPS: This pilot study supports future scholarship in 2 areas: (1) identification and assessment of additional factors that influence the relationship between ASC and academic performance across the entire undergraduate medical education curriculum and (2) development and implementation of evidence-based interventions to support student ASC and performance and enhance the learning environment. Analyzing longitudinal trends across multiple cohorts will drive evidence-based interventions at learner and programmatic levels.

OpNotes and Clinical Exercises: Activities to Enhance the Clinical Context of the Preclerkship Anatomy Dissection Laboratory.

PROBLEM: Despite numerous pedagogical approaches and technologies now available for medical gross anatomy, students can find it difficult to translate what occurs in a dissection laboratory into the context of clinical practice. APPROACH: Using complementary and collaborative approaches at 2 different medical schools, Virginia Commonwealth University (VCU) and University of Maryland (UM), we designed and implemented a series of clinical activities in the preclerkship medical gross anatomy laboratory that directly link dissected structures to clinical procedures. These activities specifically direct students to perform simulated clinically related procedures on anatomic donors during laboratory dissection sessions. The activities are called OpNotes at VCU and Clinical Exercises at UM. Each activity in the VCU OpNotes requires about 15 minutes of group activity at the end of a scheduled laboratory and involves faculty to grade the student responses submitted via a web-based-assessment form. Each exercise in UM Clinical Exercises also requires about 15 minutes of group activity during the schedule laboratory but does not involve faculty to complete grading. OUTCOMES: Cumulatively, the activities in OpNotes and Clinical Exercises both brought clinical context directly to anatomical dissections. These activities began in 2012 at UM and 2020 at VCU, allowing a multiyear and multi-institute development and testing of this innovative approach. Student participation was high, and perception of its effectiveness was almost uniformly positive. NEXT STEPS: Future iterations of the program will work to assess the efficacy of the program as well as to streamline the scoring and delivery of the formative components. Collectively, we propose that the concept of executing clinic-like procedures on donors in anatomy courses is an effective means of enhancing learning in the anatomy laboratory while concurrently underscoring the relevance of basic anatomy to future clinical practice.

A mixed methods exploration of the emergence of goal orientation in medical students' individualized learning plans.

PURPOSE: Goal orientation (GO) describes an individual's approach to different achievement situations. Understanding the motivations and approach to achieving goals of medical students is vital with the increasing emphasis on self-directed learning. The purpose of this study was to identify themes in self-improvement reflections that relate to each GO dimension (learning, performance-prove, and performance-avoid). METHODS: A sequential explanatory mixed methods design was used. GO data was used to categorize students into groups aligning with the GO dimension identified in the previous stage of quantitative analysis. Individualized learning plans (ILPs) for each GO dimension group were coded inductively to identify emergent themes related to goal setting and achievement. RESULTS: The learning GO group was the largest of the three GOs. Five themes were identified from inductive analysis: importance of practice, identifying elements that helped, identifying structural barriers, opportunities for improvement, and acknowledging experience. While these themes occur across GO, patterns exist within their ILPs based on GO. CONCLUSIONS: We identified common themes for motivations of medical students, and these motivations might differ depending on their GO. Further exploration into the themes over the course of their training will provide additional insights on what factors may be involved in student motivations towards learning and achievement. Educators can use this information to individualize feedback and students can better understand their motivations towards achieving goals.

Telehealth Training for Surgeons to Empathetically Deliver Bad News Via Video-Mediated Communication.

BACKGROUND: The COVID-19 pandemic resulted in a sudden increase in the need to effectively use telehealth in all realms of health care communication, including the delivery of bad news. METHODS: A single arm, unblinded, feasibility study was performed at a tertiary care center located in Central Virginia to explore the value and utility of providing a telehealth training program based on SPIKES to teach surgical residents and faculty best practice for disclosing difficult news via video-mediated communication (VMC). Surgical interns (categorical and preliminary), surgical residents, and surgical faculty from General, Neuro, Pediatric, Plastics, Oncology, Urology, and Vascular surgical specialties were recruited via email to voluntarily participate in a telehealth simulation-based workshop, with 33 surgical learners participating in the training and 28 completing evaluation surveys. RESULTS: Only six respondents (22%) indicated they had prior formal training on telehealth communication with patients or families, while 13 (46%) said they had prior experience giving bad news via telehealth. Comments about improving the training focused on providing more scenarios to practice and more time for feedback. Overall, 25 learners (86%) agreed the activity was a valuable learning experience and the majority (61%) of responses were positive for future use of telehealth for breaking bad news. DISCUSSION: Practicing communication skills with VMC was found to be valuable by surgical interns, residents, and faculty. Formal training should be provided for surgeons at every stage of training and practice to improve skill in the delivery of bad news to patients and their families.

From chaos to creativity: Designing collaborative communication training for the delivery of bad news.

BACKGROUND: Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines. METHODS: The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields. RESULTS: Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session. CONCLUSION: We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

The Role for Simulation in Professional Identity Formation in Medical Students.

INTRODUCTION: Authentic clinical experiences and reflection are critical for medical student professional identity formation (PIF). Individualized learning plans and competency-based education accelerate time to graduation, thus creating more demand for students to gain PIF experiences early in medical education. This pilot study investigated student professional identity experiences related to participation in a clinical simulation during the first week of medical school. METHODS: All first-year medical students at an academic health center participated in a clinically relevant simulation-based orientation to medical school (SOMS). Participants completed evaluation surveys measuring PIF-related experiences during the SOMS. RESULTS: All participants completed the survey (N = 186). Students agreed that the SOMS helped them feel what it is like to be a doctor (90%) and transition to the role of student-physician (91%). Student comments about the SOMS-reflected PIF-related processes, such as building a sense of a community of practice among their peers in their roles as a healthcare team. Students also valued the opportunity to engage in reflection about their roles as student-physicians. CONCLUSIONS: Simulation experiences can be used as a trigger for self-reflection to assist in medical student professional identity development as early as the first weeks of medical school. Simulation exercises may improve PIF and could further enhance medical student PIF by adding them longitudinally into the curriculum.

Addiction curriculum design for medical students.

BACKGROUND: As mortality and morbidity due to substance use disorder (SUD) are increasing for women, especially during pregnancy and postpartum, it is imperative to equip medical providers with skills to identify SUD and initiate treatments. We designed a curriculum to provide third-year medical students with clinical exposure to SUD during pregnancy. APPROACH: This novel, experience-based SUD curriculum was focused on providing adequate knowledge, skills and confidence to provide compassionate, patient-centred care to women with SUD. Obstetrics and Gynecology clerkship third-year medical students rotated 1 day through a clinic that provides Obstetrics and Gynecology and addiction medicine services. Congruent with COVID-19 limitations, students completed pre-clinic assignments and in-clinic tasks (e.g., screening, brief intervention, referral to treatment [SBIRT]) under supervision. EVALUATION: After implementation of this pilot curriculum, 20 students and 10 teachers completed surveys (100% response rate) with open-ended response items. Quantitative data and open-ended responses using electronic surveys were sequentially analysed to evaluate the curriculum's feasibility and acceptability. IMPLICATIONS: We designed a novel curriculum that focused on SUD learning objectives and providing exposure to third-year medical students, and our findings indicate that it is feasible and acceptable to both students and teachers. In the future, we plan to provide this curriculum to both our third- and fourth-year medical students, and we encourage teachers and providers at other institutions to utilise it during their clinical training.

Crashing from cadaver to computer: Covid-driven crisis-mode pedagogy spawns active online substitute for teaching gross anatomy.

In early 2020, the Covid-19 crisis forced medical institutions worldwide to convert quickly to online platforms for content delivery. Although many components of medical education were adaptable to that format, anatomical dissection laboratory lost substantial content in that conversion, including features of active student participation, three-dimensional spatial relationships of structures, and the perception of texture, variation, and scale. The present study aimed to develop and assess online anatomy laboratory sessions that sought to preserve benefits of the dissection experience for first-year medical students. The online teaching package was based on a novel form of active videography that emulates eye movement patterns that occur during processes of visual identification, scene analysis, and learning. Using this video-image library of dissected materials, content was presented through asynchronous narrated laboratory demonstrations and synchronous/active video conference sessions and included a novel, video-based assessment tool. Data were obtained using summative assessments and a final course evaluation. Test scores for the online practical examination were significantly improved over those for previous in-person dissection-based examinations, as evidenced by several measures of performance (Mean: 2015-2019: 82.5%; 2020: 94.9%; P = 0.003). Concurrently, didactic test scores were slightly, but not significantly, improved (Mean: 2015-2019: 88.0%; 2020: 89.9%). Student evaluations of online sessions and overall course were highly positive. Results indicated that this innovative online teaching package can provide an effective alternative when in-person dissection laboratory is unavailable. Although this approach consumed considerable faculty time for video editing, further development will include video conference breakout rooms to emulate dissection small-group teamwork.

Video-mediated breaking bad news simulation.

BACKGROUND: Communication between clinicians, patients, and families is a core component of medical care that requires deliberate practice and feedback to improve. In March 2020, the COVID-19 pandemic caused a sudden transformation in communication practices because of new physical distancing requirements, necessitating physicians to communicate bad news via telephone and video-mediated communication (VMC). This study investigated students' experience with a simulation-based communications training for having difficult conversations using VMC. METHODS: Thirty-eight fourth-year medical students preparing for their surgical residency participated in a simulated scenario where students discussed a new COVID-19 diagnosis with a standardised family member (SFM) of a sick patient via VMC. Learners were introduced to an established communications model (SPIKES) by an educational video. After the simulation, SFM and course facilitators guided a debrief and provided feedback. Learners completed surveys evaluating reactions to the training, preparedness to deliver bad news, and attitudes about telehealth. RESULTS: Twenty-three students completed evaluation surveys (response rate=61%). Few students had prior formal training (17%) or experience communicating bad news using telehealth (13%). Most respondents rated the session beneficial (96%) and felt they could express empathy using the VMC format (83%). However, only 57% felt ready to deliver bad news independently after the training and 52% reported it was more difficult to communicate without physical presence. Comments highlighted the need for additional practice. CONCLUSION: This pilot study demonstrated the value and feasibility of teaching medical students to break bad news using VMC as well as demonstrating the need for additional training.

Increasing Knowledge and Self-Efficacy on Differences in Sex Development (DSD): A Team-Based Learning Activity for Pediatric Residents.

Introduction: Differences in sex development (DSD) are a heterogenous group of conditions estimated to affect 1 in 4500 infants. A paradigm shift has occurred in societal and cultural acceptance of variant gender outcomes along with increased awareness around diagnostic uncertainty inherent to DSD. Lack of provider knowledge in evaluation of DSD and/or awareness of evolving paradigms relevant to care for patients with DSD can accentuate barriers to access optimal care for this already vulnerable population. Methods: To address this unmet need, we used Kern's six-step framework and piloted a team-based learning (TBL) activity for pediatric residents and medical students (36 learners). This included preactivity reading, an 11-item self-efficacy survey around treatment of patients with DSD at the beginning of the TBL, and a seven-question individual readiness assurance test (RAT). Mixed teams of five to seven learners completed the RAT in small groups followed by large-group discussion. An application exercise followed with two cases focused on initial evaluation of a newborn/child with suspected DSD and an older child with suspected DSD. At the conclusion, learners repeated the self-efficacy measure and answered several evaluation questions. Results: Individual RAT scores had a mean of 59%, while groups scored with a mean of 82%. Mean self-efficacy scores also increased significantly from 2.4 to 3.4 on a 5-point scale. Of learners, 80% agreed or strongly agreed that the activity was effective for improving DSD skills and knowledge. Discussion: TBL is a valuable educational strategy to enhance knowledge and self-efficacy of DSD care for general pediatricians.

Who belongs in school? Examining the link between Black and White racial disparities in sense of school belonging and suspension.

Relative to White students, Black students experience higher rates of exclusionary discipline and less welcoming school environments. However, little empirical research has examined the extent to which these two parallel racial disparities are linked. This study examines the relationship between student race and suspension and whether this relationship depends on school-level racial disparities in students' sense of school belonging. Using data from 73,755 students (56.4% White, 43.6% Black or African-American) nested within 131 schools, this study uses a series of multilevel models with cross-level interactions. This study finds that Black students are consistently more likely to be suspended than White students, but this difference is nonsignificant in schools where Black students' sense of school belonging is much higher than that of White students'. As such, schools' efforts toward reducing the discipline gap may benefit from making schools more welcoming to Black students.