'I sound different, I look different, I am different': Protecting and promoting the sense of authenticity of ethnically minoritised medical students.

BACKGROUND: Being authentic can improve students' well-being and enhance the medical student-patient communication and patient safety. However, the underrepresentation of ethnically minoritised students in medical education can result in identity suppression, interfering with students' ability to succeed academically and professionally. METHODS: We conducted interviews with 20 ethnically minoritised medical students, which were analysed thematically, to explore the following: What facilitates and prevents students from being their authentic self during medical school? What learning and teaching strategies can enable students to be or become their authentic self? FINDINGS: Experiences of discrimination, microaggressions and/or racism were the main barriers to authenticity, leading to fear of being discriminated again if students expressed their true self. Lack of diversity, cultural awareness and staff representation were also fundamental barriers. Being authentic was often perceived as contradictory to being professional and a risk that could damage students' reputation. However, when students could express their true self, they felt happier, safer and developed a stronger sense of belonging. DISCUSSION: To enhance authenticity, students need to see better staff representation, role models they can relate and aspire to, such as Black professors. Equity/Diversity/Inclusion/Belonging (EDIB) training needs to become embedded throughout the curriculum and be delivered by facilitators with lived experiences. Other strategies to promote students' authenticity included mentoring, better signposting to complaints procedure and well-being resources and implementation of 'zero tolerance' policies. To our knowledge, this is one of the first studies on the concept of authenticity in medical education and the first study focusing on ethnically minoritised students.

Medical students impacted by discrimination: a qualitative study into their experiences of belonging and support systems at medical schools in the UK.

OBJECTIVE: To better understand the broader experience of medical students impacted by discrimination and the support systems they engage with. DESIGN: Qualitative study using semi-structured interviews. SETTING: Four medical schools based in the UK. PARTICIPANTS: 17 medical students were recruited using volunteer and snowball sampling: all students self-identified as being impacted by discrimination. RESULTS: 5 themes were identified: feelings of isolation, imposter syndrome and exclusion; a lack of representation and positive role modelling; the importance of peer support; issues relating to the accessibility of support; building support networks through shared experiences and attempts to foster a sense of inclusion through peer and institutionally led initiatives. CONCLUSIONS: The findings of this study suggest medical schools could do more to recognise the importance of acknowledging the multiple identities at risk of discrimination held by students, perpetuating feelings of isolation and exclusion. Our research highlights the need for practical systemic initiatives to improve the sense of belonging of medical students who are impacted by discrimination. Medical educators and institutions should consider formal and informal provisions, such as creating time and space for students to meet and share experiences, access support and reporting networks, to foster a greater sense of belonging.

Learning machines or the key to care: a qualitative study exploring the impact of the hidden curriculum on medical students' longitudinal experiences in primary care.

OBJECTIVE: Longitudinal learning often faces implementation challenges within UK medical schools. Some have suggested that the hidden curriculum may be implicated, but there is little evidence regarding how the hidden curriculum influences student experiences of, and engagement with longitudinal learning. Given this, our objective was to explore the impact of the hidden curriculum on student experiences of a longitudinal curriculum based in primary care at a research-intensive medical school. DESIGN: We conducted a longitudinal qualitative study. Students participated in three serial, in-depth semistructured interviews. We conducted a longitudinal thematic analysis. SETTING: One research-intensive medical school based in the UK. Data collection occurred in 2021-2022. PARTICIPANTS: 12 penultimate year medical students taking part in a longitudinal primary care placement for 1 day a week over the course of one academic year. RESULTS: We constructed four themes capturing insights on how hidden curricula influenced students' experiences: (1) A culture which stresses assessment influences student engagement with longitudinal learning; (2) Longitudinal relationships can challenge the hidden curriculum; (3) Support and continuity within primary care improves skills and can influence belonging and (4) Logistical issues influence engagement with longitudinal learning. CONCLUSIONS: The hidden curriculum, particularly related to assessment, plays a large role in student perceptions of educational value and subsequent engagement with curricula. In a research-intensive institution, longitudinal learning, particularly within primary care, was perceived as at odds with what was important for assessments. Where longitudinal relationships were successfully established, students became more aware of the benefits of person-centred practice. For primary care longitudinal education to succeed in more research-intensive institutions, there must first be advocacy for greater representation of primary care and person-centred values within organisational structures to ensure meaningful curricular alignment.

Community action projects: community-engaged quality improvement for medical students.

BACKGROUND: Healthcare Quality Improvement (QI) is an essential skill for medical students to acquire, although there is insufficient empirical research which suggests the best educational methods to do this. This study explored the experiences of medical students participating in two versions of a Community Action Project (CAP) which gave medical students the opportunity to learn QI skills in a community setting. The first version (GPCAP) was pre-pandemic where students identified and delivered QI projects on placement in general practice to improve local population health. The second version (Digi-CAP) ran remotely where students worked on QI projects identified by local voluntary sector organisations focused on local community priorities during COVID-19. METHODS: Semi-structured interviews were conducted with volunteers from the two cohorts of students who had taken part in quality improvement initiatives. Transcriptions were independently coded by two researchers and analysed through thematic analysis. RESULTS: Sixteen students were interviewed. Whilst students had mixed experiences of completing their CAP, engagement and successful learning was associated with the following themes from the two versions of QI CAP projects: finding a sense of purpose and meaning in QI projects; preparedness for responsibility and service-driven learning; the importance of having supportive partnerships throughout the project duration and making a sustainable difference. CONCLUSIONS AND IMPLICATIONS: The study provides valuable insights into the design and implementation of these community-based QI projects, which enabled students to learn new and often hard to teach skills, whilst working on projects which have a sustainable impact on local community outcomes.

A contextual definition of longitudinal integrated clerkships within the UK and Ireland: A bi-national modified Delphi study.

Disagreement exists within the UK and Ireland regarding how Longitudinal Integrated Clerkships should be defined, and the relevance of international definitions. In this modified, online Delphi study, we presented the UK and Ireland experts in Longitudinal Integrated Clerkships with statements drawn from international definitions, published LIC literature, and the research team's experience in this area and asked them to rate their level of agreement with these statements for inclusion in a bi-national consensus definition. We undertook three rounds of the study to try and elicit consensus, making adaptations to statement wording following rounds 1 and 2 to capture participants' qualitative free text-comments, following the third and final round, nine statements were accepted by our panel, and constitute our proposed definition of Longitudinal Integrated Clerkships within the UK and Ireland. This definitional statement corresponds with some international literature but offers important distinctions, which account for the unique context of healthcare (particularly primary care) within the UK and Ireland (for example, the lack of time-based criteria within the definition). This definition should allow UK and Irish researchers to communicate more clearly with one another regarding the benefits of LICs and longitudinal learning and offers cross-national collaborative opportunities in LIC design, delivery and evaluation.

ExoDx prostate test as a predictor of outcomes of high-grade prostate cancer - an interim analysis.

BACKGROUND: Patient outcomes were assessed based on a pre-biopsy ExoDx Prostate (EPI) score at 2.5 years of the 5-year follow-up of ongoing prostate biopsy Decision Impact Trial of the ExoDx Prostate (IntelliScore). METHODS: Prospective, blinded, randomized, multisite clinical utility study was conducted from June 2017 to May 2018 (NCT03235687). Urine samples were collected from 1049 men (≥50 years old) with a PSA 2-10 ng/mL being considered for a prostate biopsy. Patients were randomized to EPI vs. standard of care (SOC). All had an EPI test, but only EPI arm received results during biopsy decision process. Clinical outcomes, time to biopsy and pathology were assessed among low (<15.6) or high (≥15.6) EPI scores. RESULTS: At 2.5 years, 833 patients had follow-up data. In the EPI arm, biopsy rates remained lower for low-risk EPI scores than high-risk EPI scores (44.6% vs 79.0%, p < 0.001), whereas biopsy rates were identical in SOC arm regardless of EPI score (59.6% vs 58.8%, p = 0.99). Also in the EPI arm, the average time from EPI testing to first biopsy was longer for low-risk EPI scores compared to high-risk EPI scores (216 vs. 69 days; p < 0.001). Similarly, the time to first biopsy was longer with EPI low-risk scores in EPI arm compared to EPI low-risk scores in SOC arm (216 vs 80 days; p < 0.001). At 2.5 years, patients with low-risk EPI scores from both arms had less HGPC than high-risk EPI score patients (7.9% vs 26.8%, p < 0.001) and the EPI arm found 21.8% more HGPC than the SOC arm. CONCLUSIONS: This follow-up analysis captures subsequent biopsy outcomes and demonstrates that men receiving EPI low-risk scores (<15.6) significantly defer the time to first biopsy and remain at a very low pathologic risk by 2.5-years after the initial study. The EPI test risk stratification identified low-risk patients that were not found with the SOC.

Responsibility driven learning in primary care: a qualitative evaluation of a medical student COVID-19 volunteering programme.

BACKGROUND: During the first wave of the pandemic when clinical placements were suspended, a UK medical student volunteering programme was developed to support local GP practices. This study aimed to explore the impact that volunteering in primary care had on students' learning and professional development to inform the design of future service-learning curricula innovations. METHODS: Seventy medical students across all years volunteered across forty-five GP practices in north-west London. Ten volunteer students and six GPs who had hosted students volunteered to participate in remotely conducted, semi-structured interviews with a researcher. Transcriptions were independently coded by two researchers and analysed by thematic analysis using service learning and communities of practice as sensitising concepts. RESULTS: Analysis showed a strong alignment between the views of students and GPs in terms of perceived learning. Our analysis of both sets of interviews resulted in five themes describing student outcomes from the volunteering scheme: developing as a doctor, understanding the complexity of medicine, responsibility driven learning, a meaningful role in a community of practice, and seeing behind the scenes in primary care. DISCUSSION AND CONCLUSION: Results from this study highlighted how a meaningful service-led role and responsibility in primary care can empower and motivate students to learn beyond the traditional medical curriculum and assessments. Adopting these new 'pro-active' roles within general practices led volunteers, particularly those in the early years of study, to develop a better understanding of primary care and medical complexity. It also enhanced their professional skills, attitudes and behaviours, while having a beneficial impact on patient care during the pandemic.

Identity Development in Disorientating Times: the Experiences of Medical Students During COVID-19.

Introduction: Professional identity development is a central aim of medical education, which has been disrupted during COVID-19. Yet, no research has qualitatively explored COVID-19's impact across institutions or countries on medical students' identities. Kegan proposes a cognitive model of identity development, where 'disorientating dilemmas' prompt student development. Given the potential of COVID-related disruption to generate disorientating dilemmas, the authors investigated the ways in which COVID-19 influenced students' identity development. Methods: The authors conducted an international qualitative study with second year medical students from Imperial College London, and third year students from Melbourne Medical School. Six focus groups occurred 2020-2021, with three to six students per group. Authors analysed data using reflexive thematic analysis, applying Kegan's model as a sensitising theoretical lens. Results: COVID-19 has resulted in a loss of clinical exposure, loss of professional relationships, and a shift in public perception of physicians. Loss of exposure to clinical practice removed the external validation from patients and seniors many students depended on for identity development. Students' experiences encouraged them to assume the responsibilities of the profession and the communities they served, in the face of conflicting demands and risk. Acknowledging and actioning this responsibility facilitated identity development as a socially responsible advocate. Conclusions: Educators should consider adapting medical education to support students through Kegan's stages of development. Measures to foster relationships between students, patients, and staff are likely necessary. Formal curricula provisions, such as spaces for reflection and opportunities for social responsibility, may aid students in resolving the conflict many have recently experienced. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01592-z.

The impact of Covid-19 on professional identity formation: an international qualitative study of medical students' reflective entries in a Global Creative Competition.

INTRODUCTION: The Covid-19 pandemic, which affected medical students globally, could be viewed as a disorientating dilemma with the potential to offer opportunities for transformative learning. In 2021 the Medical Education Innovation and Research Centre at Imperial College London launched a Global Creative Competition as a platform for medical students to reflect on their experiences during the pandemic. METHODS: Six hundred forty-eight creative pieces with written reflections were submitted by medical students from 52 countries. 155 students from 28 countries consented for their entries to be included in this study. The reflections were analysed thematically and independently by three reviewers to explore how the pandemic impacted students' professional identity formation (PIF). RESULTS: The pandemic increased students' awareness of the social and global role of doctors in addressing health inequities. Students felt part of a wider healthcare community and showed greater appreciation towards person-centred care. Students also became more aware of their personal needs, priorities, and the importance of self-care. DISCUSSION: In agreement with Mezirow's theory of transformative learning (2003), the pandemic led students to re-examine pre-existing epistemic and sociocultural assumptions concerning the role of doctors and explore new perspectives of what it means to be a doctor. In accordance with Cheng's theory of coping flexibility (2021), students developed both emotion-focused coping strategies (e.g., arts engagement) and problem-solving strategies (e.g., volunteering), suggesting they were able to adjust psychologically and develop agency. However, students experienced tension between their sense of duty and sense of wellbeing, highlighting the need for medical educators to design into programmes formal support systems where medical students have the space and time they need to reflect on their emergent identities as a doctor. CONCLUSION: Medical educators should encourage students to reflect on their identity formation while encountering disorientating dilemmas. The inclusion of arts and humanities within the medical curriculum is strongly recommended to provide an avenue for students to access and express complex emotions and experiences.

Using vlogging to facilitate medical student reflection.

Reflection is a critical skill for medical professionals, however medical students often find it difficult to grasp and engage with. During a special choice module on yoga and mindfulness, students practised mindfulness at home and posted their reflections on the activities in text and vlogs in a closed WhatsApp group. Semi-structured focus groups investigated student perspectives on the acceptability and impact of v-logging on their reflective practice. We thematically analysed transcripts of the WhatsApp conversations and two focus groups.Students felt v-logging was more engaging and convenient than written reflections. V-logging was found to enhance emotional content that is commonly lacking in written reflection, which is has importance as emotional recognition promotes a higher quality of reflection. Although some students were concerned about their appearance in videos, they appeared to overcome this, finding v-logging facilitated deeper reflection compared with traditional written reflections due to accessibility and ease of expression. Furthermore, there was additional learning through watching other students' emotive vlogs which fits with the phenomenon of reflective vicarious learning.Sharing vlogs within a WhatsApp group appeared to be an accessible way for facilitating greater engagement with affective and expressive aspects of reflection.

Cultural diversity and inclusion in UK medical schools.

BACKGROUND: Racially minoritised groups across the globe continue to experience differential outcomes in both health and education. Medical schools can play an instrumental role in addressing both these disparities, by creating inclusive student communities and ensuring that tomorrow's doctors can care for our increasingly diverse populations. OBJECTIVES: This collaborative, qualitative study led by three United Kingdom (UK) institutions aimed to explore the perspectives of Heads of Primary Care Teaching (HOTs) on cultural diversity and inclusion across UK medical schools. METHODS: In December 2020, five focus groups were conducted remotely with 23 HOTs, or a nominated deputy. We explored participants' opinions regarding opportunities and barriers to cultural diversity and inclusion in medical education, ways to overcome these challenges and shared examples of best practice. Data were transcribed verbatim and thematically analysed by three researchers. RESULTS: Investigators identified six themes from the data: lack of faculty diversity, tokenistic faculty training, institutional mindset, diversifying the formal and hidden curricula, intersectionality and student voice. CONCLUSION: Medical schools worldwide face similar challenges, uncertainties and opportunities when integrating diversity and inclusion throughout the learning environment. Although the importance of the topic is increasingly acknowledged, current efforts are viewed as being passive and tokenistic, hindered by challenges at multiple levels. Partnership with students and collaboration within and between institutions nationally and internationally will enable us to move forwards with both local and global positive, sustainable change.

Pre-diagnosis urine exosomal RNA (ExoDx EPI score) is associated with post-prostatectomy pathology outcome.

PURPOSE: ExoDx Prostate IntelliScore (EPI) is a non-invasive urine exosome RNA-based test for risk assessment of high-grade prostate cancer. We evaluated the association of pre-biopsy test results with post-radical prostatectomy (RP) outcomes to understand the potential utility of EPI to inform invasive treatment vs active surveillance (AS) decisions. METHODS: Urine samples were collected from 2066 men scheduled for initial biopsy with PSA between 2 and 10 ng/mL, no history of prostate cancer, and ≥ 50 years across multiple clinical studies. 310 men proceeded to RP, of which 111 patients had Gleason group grade 1 (GG1) at biopsy and would have been potential candidates for AS. We compared pre-biopsy urine scores with ERSPC and PCPT multivariate risk calculator scores for men with GG1 at biopsy to post-RP pathology. RESULTS: Urine EPI scores were significantly lower in men with GG1 at biopsy than in men with > GG1 (p = 0.04), while there were no differences in multivariate risk scores used in standard clinical practice (p > 0.05). Further, EPI scores were significantly lower in men with GG1 at biopsy who remained GG1 post-RP compared to men upgraded to ≥ GG3 post-RP (p < 0.001). In contrast, none of the multiparametric risk calculators showed significant differences (p > 0.05). Men with GG1 at biopsy and EPI score < 15.6 had zero rate of upgrading to ≥ GG3 post-RP compared to 16.0% for EPI scores ≥ 15.6. CONCLUSIONS: The EPI urine biomarker outperformed the multivariate risk calculators in a homogenous risk group of pre-biopsy men. The EPI score was associated with low-risk pathology post-RP, with potential implications on informing AS decisions. TRIAL REGISTRATION: NCT02702856, NCT03031418, NCT03235687, NCT04720599.

Community-engaged medical education: helping to address child health and social inequality.

Medical education has a key role in helping to address child health and social inequality. In this paper we describe the rationale for developing a community-engaged approach to education, whereby medical schools partner with local communities. This symbiotic relationship enables medical students to experience authentic learning through working with communities to address local health and social priorities. Case studies of how such approaches have been implemented are described, with key takeaway points for paediatric healthcare professionals wanting to develop community-engaged educational initiatives.

WATCCH: a multiprofessional approach to widening participation in healthcare careers.

BACKGROUND: Students from lower socioeconomic backgrounds are underrepresented in higher education and healthcare careers. Whilst most healthcare-related widening participation schemes focus on one healthcare profession, the Widening Access to Careers in Community Healthcare (WATCCH) programme at Imperial College London supports participation in a range of community healthcare careers. We aim to evaluate the impact of WATCCH on students' perceptions and aspirations towards community healthcare careers. METHOD: WATCCH provides educational and application support to 16-18 year-old students interested in a variety of community healthcare careers via work experience, educational workshops and mentoring. The programme was evaluated by focus groups using semi-structured questions to explore the impact of WATCCH on students' healthcare career perceptions and aspirations. RESULTS: Five themes were identified from the focus groups: increased awareness and understanding of a range of community healthcare careers; improved insight into the realities of healthcare careers enabling reflection on career aspirations; altered perceptions of healthcare professionals and acquisition of new role models; increased confidence in achieving a career in healthcare; and valued access to previously inaccessible work experience. DISCUSSION: WATCCH is a multi-professional widening participation programme that has supported students from lower socioeconomic backgrounds interested in entering healthcare careers by increasing insights into varied healthcare careers, provision of role models, and increasing students' confidence of ability to enter healthcare careers. Similar programmes in other institutions could support large numbers of aspiring students to enter varied community healthcare careers in the future.

The do's, don'ts and don't knows of redressing differential attainment related to race/ethnicity in medical schools.

INTRODUCTION: Systematic and structural inequities in power and privilege create differential attainment whereby differences in average levels of performance are observed between students from different socio-demographic groups. This paper reviews the international evidence on differential attainment related to ethnicity/race in medical school, drawing together the key messages from research to date to provide guidance for educators to operationalize and enact change and identify areas for further research. METHODS: Authors first identified areas of conceptual importance within differential attainment (learning, assessment, and systems/institutional factors) which were then the focus of a targeted review of the literature on differential attainment related to ethnicity/race in medical education and, where available and relevant, literature from higher education more generally. Each author then conducted a review of the literature and proposed guidelines based on their experience and research literature. The guidelines were iteratively reviewed and refined between all authors until we reached consensus on the Do's, Don'ts and Don't Knows. RESULTS: We present 13 guidelines with a summary of the research evidence for each. Guidelines address assessment practices (assessment design, assessment formats, use of assessments and post-hoc analysis) and educational systems and cultures (student experience, learning environment, faculty diversity and diversity practices). CONCLUSIONS: Differential attainment related to ethnicity/race is a complex, systemic problem reflective of unequal norms and practices within broader society and evident throughout assessment practices, the learning environment and student experiences at medical school. Currently, the strongest empirical evidence is around assessment processes themselves. There is emerging evidence of minoritized students facing discrimination and having different learning experiences in medical school, but more studies are needed. There is a pressing need for research on how to effectively redress systemic issues within our medical schools, particularly related to inequity in teaching and learning.

Medical students' experience of the hidden curriculum around primary care careers: a qualitative exploration of reflective diaries.

OBJECTIVES: Primary healthcare internationally is facing a workforce crisis with fewer junior doctors choosing general practice (GP) as a career. In the UK, a national report on GP careers highlighted adverse influences during medical school on students' career choices. The authors explored these influences in two urban UK medical schools, both with relatively low numbers of students entering GP training. DESIGN: Using a phenomenological approach, the authors thematically analysed the reflective diaries of four medical students who were recruited as 'participant researchers' over a period of 10 months. These students made regular reflexive notes about their experiences related to GP career perceptions in their academic and personal environments, aiming to capture both positive and negative perceptions of GP careers. The research team discussed emerging data and iteratively explored and developed themes. SETTING: Two UK medical schools PARTICIPANTS: Undergraduate medical students RESULTS: Seven key themes were identified: the lack of visibility and physicality of GP work, the lack of aspirational GP role models, students' perceptions of a GP career as default, the performativity of student career choice with the perceptions of success linked to specialism, societal perceptions of GP careers, gender stereotyping of career choices and the student perception of life as a GP. CONCLUSIONS: Students overwhelmingly reflected on negative cues to GP careers, particularly through their experience of the hidden curriculum. Three recommendations are made: the need for increased representation of GP role models in clinical curricula content delivery and senior leadership; ensuring GP clerkships involve an active and authentic student role with patients, enabling students to experience GP's 'work' including managing complexity, uncertainty and risk. Finally, institutions need to consider students' experiences of the hidden curriculum and the effect this can have on students' perception of careers, alongside the challenges of rankings and perceived hierarchical positioning of disciplines.

Promoting cultural diversity and inclusion in undergraduate primary care education.

In this article, we review key factors in promoting a culturally diverse and inclusive learning environment for all undergraduate medical students, and the role of primary care educators in preparing students to work with diverse teams, patients and communities. These factors include approaches to curriculum and assessment, student community, faculty development and recruitment, and wider institutional factors. By highlighting these, including areas where further research, evaluation and consensus are needed, we hope to support further discourse on how primary care educators can promote culturally diverse and inclusive undergraduate medical education.