A Sense of Belonging: Perceptions of the Medical School Learning Environment among URM and Non-URM Students.

Phenomenon: Improving the learning environment (LE), particularly for students underrepresented in medicine (URM), has become an important goal for institutions that provide undergraduate and graduate medical education. Until recently, research and intervention development have been limited by the lack of comprehensive theoretical frameworks. A multi-dimensional conceptual model of the medical school environment, developed by Gruppen and colleagues in 2019, provides a useful framework for guiding research and interventions in this area.Approach: Using Gruppen et al's model, this study investigated experiences of the LE from the perspectives of both URM and non-URM students at a medical school in New York City. In examining experiences of the organizational, social, and physical domains of the LE, we sought to explore the symbolic and experiential links across domains and identify concrete needs for improvement.Findings: Institutional structures and policies, features of the built environment, and social relationships that put learning first and generated a sense of community were highly valued. Although both URM and non-URM students shared many perceptions and experiences, URM students expressed heightened vulnerability to the experiences of devaluation and exclusion.Insights: All participants in the study greatly appreciated aspects of the LE that made them feel like valued members of the community. Medical schools should approach the task of improving the LE for URM students using a comprehensive, multi-dimensional approach.

Moral injury and the hidden curriculum in medical school: comparing the experiences of students underrepresented in medicine (URMs) and non-URMs.

Underrepresented students in medicine (URM) have more negative perceptions of the medical school learning environment (LE), a phenomenon that can contribute to higher rates of burnout and attrition in these populations. The hidden curriculum (HC)-defined as a set of values informally conveyed to learners through clinical role-modeling-is a LE socialization construct that has been critically examined for its role in shaping students' professional identities. Yet differences in how URMs and non-URMs experience the HC remain underexplored. The study used a pragmatic approach that drew on elements of grounded theory and employed both deductive and inductive reasoning. Investigators conducted qualitative, semi-structured interviews with a purposive sample of 13 URM and 21 non-URM participants at a Bronx, NY medical school. Interviews examined student experiences and reactions to the HC. Both cohorts witnessed patient disparagement and mistreatment. However, from these encounters, URM participants expressed more moral injury-the adverse emotional consequence of feeling pressured to accept ideologically incongruent values. URMs were also more likely to describe resisting the HC. Differences in group reactions appeared to arise from URMs' identity resonance with patients' lived experiences. Participants across cohorts emphasized increasing URM recruitment as one step toward mitigating these circumstances. URM participants experienced more distress and offered more resistance to the HC relative to non-URMs. The etiology of these differential reactions may stem from relative barriers in negotiating personal and professional identities. As such, URMs' perceptions of the LE may be adversely impacted given their more negative interactions with the HC.

Novel use of an OSCE to assess medical students' responses to a request for a low value diagnostic imaging test: A mixed methods analysis.

OBJECTIVE: Evaluate medical students' communication skills with a standardized patient (SP) requesting a low value test and describe challenges students identify in addressing the request. METHODS: In this mixed-methods study, third-year students from two medical schools obtained a history, performed a physical examination, and counseled an SP presenting with uncomplicated low back pain who requests an MRI which is not indicated. SP raters evaluated student communication skills using a 14-item checklist. Post-encounter, students reported whether they ordered an MRI and challenges faced. RESULTS: Students who discussed practice guidelines and risks of unnecessary testing with the SP were less likely to order an MRI. Students cited several challenges in responding to the SP request including patient characteristics and circumstances, lack of knowledge about MRI indications and alternatives, and lack of communication skills to address the patient request. CONCLUSIONS: Most students did not order an MRI for uncomplicated LBP, but only a small number of students educated the patient about the evidence to avoid unnecessary imaging or the harm of unnecessary testing. PRACTICE IMPLICATIONS: Knowledge about unnecessary imaging in uncomplicated LBP may be insufficient to adhere to best practices and longitudinal training in challenging conversations is needed.

Assessing Student Competencies in Antibiotic Stewardship and Patient Counseling.

BACKGROUND AND OBJECTIVES: Antibiotic misuse contributes to antibiotic resistance and is a growing public health threat in the United States and globally. Professional medical societies promote antibiotic stewardship education for medical students, ideally before inappropriate practice habits form. To our knowledge, no tools exist to assess medical student competency in antibiotic stewardship and the communication skills necessary to engage patients in this endeavor. The aim of this study was to develop a novel instrument to measure medical students' communication skills and competency in antibiotic stewardship and patient counseling. METHODS: We created and pilot tested a novel instrument to assess student competencies in contextual knowledge and communication skills about antibiotic stewardship with standardized patients (SP). Students from two institutions (N=178; Albert Einstein College of Medicine and Warren Alpert Medical School of Brown University) participated in an observed, structured clinical encounter during which SPs trained in the use of the instrument assessed student performance using the novel instrument. RESULTS: In ranking examinee instrument scores, Cronbach α was 0.64 (95% CI: 0.53 to 0.74) at Einstein and 0.71 (95% CI: 0.60 to 0.79) at Brown, both within a commonly accepted range for estimating reliability. Global ratings and instrument scores were positively correlated (r=0.52, F [3, 174]=30.71, P<.001), providing evidence of concurrent validity. CONCLUSIONS: Similar results at both schools supported external validity. The instrument performed reliably at both institutions under different examination conditions, providing evidence for the validity and utility of this instrument in assessing medical students' skills related to antibiotic stewardship.

Leadership Pathways in Academic Family Medicine: Focus on Underrepresented Minorities and Women.

BACKGROUND AND OBJECTIVES: Leadership positions in academic medicine lack racial and gender diversity. In 2016, the Council of Academic Family Medicine (CAFM) established a Leadership Development Task Force to specifically address the lack of diversity among leadership in academic family medicine, particularly for underrepresented minorities and women. APPROACH: The task force was formed in August 2016 with members from each of the CAFM organizations representing diversity of race, gender, and academic position. The group met from August 2016 to December 2017. The task force reviewed available leadership development programming, and through consensus identified common pathways toward key leadership positions in academic family medicine-department chairs, program directors, medical student education directors, and research directors. consensus development: The task force developed a model that describes possible pathways to several leadership positions within academic family medicine. Additionally, we identified the intentional use of a multidimensional mentoring team as critically important for successfully navigating the path to leadership. CONCLUSIONS: There are ample opportunities available for leadership development both within family medicine organizations and outside. That said, individuals may require assistance in identifying and accessing appropriate opportunities. The path to leadership is not linear and leaders will likely hold more than one position in each of the domains of family medicine. Development as a leader is greatly enhanced by forming a multidimensional team of mentors.

Providing Pediatric Palliative Care Education Using Problem-Based Learning.

BACKGROUND: The Institute of Medicine and the American Academy of Pediatrics has called for improvement in education and training of pediatricians in pediatric palliative care (PPC). Given the shortage of PPC physicians and the immediate need for PPC medical education, this study reports the outcomes of a problem-based learning (PBL) module facilitated by academic general and subspecialty pediatric faculty (non-PPC specialists) to third year medical students. Objectives/Setting: To test the effectiveness of a PPC-PBL module on third year medical students' and pediatric faculty's declarative knowledge, attitudes toward, perceived exposure, and self-assessed competency in PPC objectives. DESIGN: A PBL module was developed using three PPC learning objectives as a framework: define core concepts in palliative care; list the components of a total pain assessment; and describe key principles in establishing therapeutic relationships with patients. A PPC physician and nurse practitioner guided pediatric faculty on facilitating the PPC-PBL. In Part 1, students identified domains of palliative care for a child with refractory leukemia and self-assigned questions to research and present at the follow-up session. In Part 2, students were expected to develop a care plan demonstrating the three PPC objectives. MEASUREMENTS: Measures included a knowledge exam and a survey instrument to assess secondary outcomes. RESULTS: Students' declarative knowledge, perceived exposure, and self-assessed competency in all three PPC learning objectives improved significantly after the PPC-PBL, p = 0.002, p < 0.001, and p < 0.001, respectively. There were no significant differences in faculty knowledge test scores from baseline to follow-up, but scores were generally high (median >80%). Students and faculty rated palliative care education as "important or very important" at baseline and follow-up. CONCLUSIONS: This study suggests that key concepts in PPC can be taught to medical students utilizing a PBL format and pediatric faculty resulting in improved knowledge and self-assessed competency in PPC.

Implementation of interprofessional education (IPE) in 16 U.S. medical schools: Common practices, barriers and facilitators.

BACKGROUND: Enhanced patient outcomes and accreditation criteria have led schools to integrate interprofessional education (IPE). While several studies describe IPE curricula at individual institutions, few examine practices across multiple institutions. PURPOSE: To examine the IPE integration at different institutions and determine gaps where there is potential for improvement. METHOD: In this mixed methods study, we obtained survey results from 16 U.S. medical schools, 14 of which reported IPE activities. RESULTS: The most common collaboration was between medical and nursing schools (93%). The prevalent format was shared curriculum, often including integrated modules (57%). Small group activities represented the majority (64%) of event settings, and simulation-based learning, games and role-play (71%) were the most utilized learning methods. Thirteen schools (81.3%) reported teaching IPE competencies, but significant variation existed. Gaps and barriers in the study include limitations of using a convenience sample, limited qualitative analysis, and survey by self-report. CONCLUSIONS: Most IPE activities focused on the physician role. Implementation challenges included scheduling, logistics and financial support. A need for effective faculty development as well as measures to examine the link between IPE learning outcomes and patient outcomes were identified.

Medical student awareness of the Patient-centered Medical Home.

BACKGROUND AND OBJECTIVES: The Patient-centered Medical Home (PCMH) has come to the forefront of primary care practice redesign and can potentially improve health care outcomes and reduce costs. There are several initiatives in medical schools to teach concepts of the PCMH to students, but it is unknown what knowledge and attitudes medical students currently possess. We report students' awareness and opinions at two medical schools without comprehensive PCMH curricula. METHODS: A total of 1,408 first- through fourth-year students at both schools were invited to participate. We distributed an electronic survey to all students via institutional e-mail listserves. Descriptive statistics were used. RESULTS: A total of 359 students participated, for a response rate of 25.5%. Despite no comprehensive curricula, 40.9% students had still encountered the topic of the PCMH. Family medicine and primary care clerkships serve as the most frequent point of exposure for students. Although many students reported not understanding the overall PCMH concept, most cited "some" understanding when presented with individually defined PCMH principles with the one exception: Value-based Payment. A significant portion of first-, second-, and third-year students rated learning about the PCMH by graduation as "important," while most fourth-year students rated this as "somewhat important." Students performed well on one knowledge question about PCMH principles; however, 29.6% of respondents believed that primary care physicians function as gatekeepers in the PCMH model. CONCLUSIONS: Medical students appear to have limited exposure and knowledge of the PCMH concept, suggesting the need to develop curricula about the PCMH in medical schools.