Applying AI and Guidelines to Assist Medical Students in Recognizing Patients With Heart Failure: Protocol for a Randomized Trial.

BACKGROUND: The integration of artificial intelligence (AI) into clinical practice is transforming both clinical practice and medical education. AI-based systems aim to improve the efficacy of clinical tasks, enhancing diagnostic accuracy and tailoring treatment delivery. As it becomes increasingly prevalent in health care for high-quality patient care, it is critical for health care providers to use the systems responsibly to mitigate bias, ensure effective outcomes, and provide safe clinical practices. In this study, the clinical task is the identification of heart failure (HF) prior to surgery with the intention of enhancing clinical decision-making skills. HF is a common and severe disease, but detection remains challenging due to its subtle manifestation, often concurrent with other medical conditions, and the absence of a simple and effective diagnostic test. While advanced HF algorithms have been developed, the use of these AI-based systems to enhance clinical decision-making in medical education remains understudied. OBJECTIVE: This research protocol is to demonstrate our study design, systematic procedures for selecting surgical cases from electronic health records, and interventions. The primary objective of this study is to measure the effectiveness of interventions aimed at improving HF recognition before surgery, the second objective is to evaluate the impact of inaccurate AI recommendations, and the third objective is to explore the relationship between the inclination to accept AI recommendations and their accuracy. METHODS: Our study used a 3 × 2 factorial design (intervention type × order of prepost sets) for this randomized trial with medical students. The student participants are asked to complete a 30-minute e-learning module that includes key information about the intervention and a 5-question quiz, and a 60-minute review of 20 surgical cases to determine the presence of HF. To mitigate selection bias in the pre- and posttests, we adopted a feature-based systematic sampling procedure. From a pool of 703 expert-reviewed surgical cases, 20 were selected based on features such as case complexity, model performance, and positive and negative labels. This study comprises three interventions: (1) a direct AI-based recommendation with a predicted HF score, (2) an indirect AI-based recommendation gauged through the area under the curve metric, and (3) an HF guideline-based intervention. RESULTS: As of July 2023, 62 of the enrolled medical students have fulfilled this study's participation, including the completion of a short quiz and the review of 20 surgical cases. The subject enrollment commenced in August 2022 and will end in December 2023, with the goal of recruiting 75 medical students in years 3 and 4 with clinical experience. CONCLUSIONS: We demonstrated a study protocol for the randomized trial, measuring the effectiveness of interventions using AI and HF guidelines among medical students to enhance HF recognition in preoperative care with electronic health record data. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49842.

The Clarion Call of the COVID-19 Pandemic: How Medical Education Can Mitigate Racial and Ethnic Disparities.

Public health crises palpably demonstrate how social determinants of health have led to disparate health outcomes. The staggering mortality rates among African Americans, Native Americans, and Latinx Americans during the COVID-19 pandemic have revealed how recalcitrant structural inequities can exacerbate disparities and render not just individuals but whole communities acutely vulnerable. While medical curricula that educate students about disparities are vital in rousing awareness, it is experience that is most likely to instill passion for change. The authors first consider the roots of health care disparities in relation to the current pandemic. Then, they examine the importance of salient learning experiences that may inspire a commitment to championing social justice. Experiences in diverse communities can imbue medical students with a desire for lifelong learning and advocacy. The authors introduce a 3-pillar framework that consists of trust building, structural competency, and cultural humility. They discuss how these pillars should underpin educational efforts to improve social determinants of health. Effecting systemic change requires passion and resolve; therefore, perseverance in such efforts is predicated on learners caring about the structural inequities in housing, education, economic stability, and neighborhoods-all of which influence the health of individuals and communities.

The Role of Medical Student Government in Responding to COVID-19.

The COVID-19 outbreak has sown clinical and administrative chaos at academic health centers throughout the country. As COVID-19-related burdens on the health care system and medical schools piled up, questions from medical students far outweighed the capacity of medical school administrators to respond in an adequate or timely manner, leaving students feeling confused and without clear guidance. In this article, incoming and outgoing executive leaders of the University of Michigan Medical School Student Council and medical school deans outline the specific ways they were able to bridge the gap between medical students and administrators in a time of crisis. To illustrate the value of student government during uncertain times, the authors identify the most pressing problems faced by students at each phase of the curriculum-preclerkship, clerkship, and postclerkship-and explain how Student Council leadership partnered with administrators to find creative solutions to these problems and provide guidance to learners. They end by reflecting on the role of student government more broadly, identifying 3 guiding principles of student leadership and how these principles enable effective student representation.

A Proposed Shared Vision for Leadership Development for all Medical Students: A Call from a Coalition of Diverse Medical Schools.

Issue: Despite clear relevance, need, descriptive literature, and student interest, few schools offer required curriculum to develop leadership skills. This paper outlines a proposed shared vision for leadership development drawn from a coalition of diverse medical schools. We advocate that leadership development is about self (looking inward), teams (not hierarchy), and change (looking outward). We propose that leadership development is for all medical students, not for a subset, and we believe that leadership curricula and programs must be experiential and applied. Evidence: This paper also draws on the current literature and the experience of medical schools participating in the American Medical Association's (AMA) Accelerating Change in Medical Education Consortium, confronts the common arguments against leadership training in medical education, and provides three cross-cutting principles that we believe must each be incorporated in all medical student-centered leadership development programs as they emerge and evolve at medical schools. Implications: By confronting common arguments against leadership training and providing a framework for such training, we give medical educators important tools and insights into developing leadership training for all students at their institutions.

Competency Committees in Undergraduate Medical Education: Approaching Tensions Using a Polarity Management Framework.

Implementing competency-based medical education in undergraduate medical education (UME) poses similar and unique challenges to doing so in graduate medical education (GME). To ensure that all medical students achieve competency, educators must make certain that the structures and processes to assess that competency are systematic and rigorous. In GME, one such key structure is the clinical competency committee. In this Perspective, the authors describe the University of Michigan Medical School's (UMMS's) experience with the development of a UME competency committee, based on the clinical competency committee model from GME, and the first year of implementation of that committee for a single cohort of matriculating medical students in 2016-2017.The UMMS competency committee encountered a number of inter dependent but opposing tensions that did not have a correct solution; they were "both/and" problems to be managed rather than "either/or" decisions to be made. These tensions included determining the approach of the committee (problem identification versus developmental); committee membership (curricular experts versus broad-based membership); student cohort makeup (phase-based versus longitudinal); data analyzed (limited assessments versus programmatic assessment); and judgments made (grading versus developmental competency assessment).The authors applied the Polarity Management framework to navigate these tensions, leveraging the strengths of each while minimizing the weaknesses. They describe this framework as a strategy for others to use to develop locally relevant and feasible approaches to competency assessment in UME.

Scaling Up a Global Health and Disparities Path of Excellence Pilot Program at the University of Michigan Medical School.

PROBLEM: Transforming medical school curricula to train physicians to better address society's needs is a complex task, as students must develop expertise in areas other than clinical medicine. APPROACH: In 2010, the University of Michigan Medical School (UMMS) launched the Global Health and Disparities (GHD) Path of Excellence as part of a larger curriculum transformation. The GHD Path is a co-curriculum with the goal of ameliorating health disparities in the United States and abroad. It was developed iteratively based on student and faculty feedback. Student feedback emphasized the value of the relationships with faculty and other students, the capstone project, and exposure to role models and professional networks. Faculty described the joy of interacting with students and the desire for recognition by their departments for their role as an advisor. OUTCOMES: Informed by the GHD Path experience, UMMS embraced the Path model, which emphasized professional relationships, career development, and high-impact scholarly work, making it different from the traditional medical curriculum, and the school implemented 7 other Paths between 2013 and 2018. Elements common to all Paths include a capstone project, a longitudinal advisor separate from the capstone advisor, exposure to role models and leaders, and the dissemination of scholarly work to promote networking. NEXT STEPS: Next steps for the Paths of Excellence include developing methods to systematically monitor students' progress, facilitating mentoring skills in and recognizing faculty advisors, and measuring the long-term impact of the Paths on students and society.

Variability in student perceptions of mistreatment.

BACKGROUND: As medical schools strive to improve the learning environment, it is important to understand medical students' perceptions of mistreatment. The purpose of this study was to explore student interpretations of previously reported mistreatment incidents to better understand how they conceptualise the interactions. METHODS: Medical students were presented with case scenarios of previously reported instances of mistreatment and asked to indicate their agreement as to whether the scenarios demonstrated mistreatment, using a five-point Likert scale (1, strongly disagree; 5, strongly agree). It is important to understand medical student's perceptions of mistreatment RESULTS: One hundred and twenty-seven third-year medical students gave feedback on 21 mistreatment cases. There was variability in the categorisation of the scenarios as mistreatment. The highest degree of consensus (96% agreement) was for a scenario in which a resident claimed a student made statements about a patient's status that the student did not make. There was also relative consensus on three additional scenarios: (1) a patient making disparaging remarks about a student's role in health care in relation to the student's ethnicity (88% agreement); (2) a resident asking a student to run personal errands (86% agreement); and (3) a nurse calling a student an expletive in front of others (77% agreement). For the majority of the cases, there was no consensus amongst students as to whether mistreatment had occurred. Students self-identifying as minorities and students who had previously reported mistreatment were more likely to perceive mistreatment in the scenarios. CONCLUSIONS: There is remarkable variability, and in many cases a lack of agreement, in medical student perceptions of mistreatment. This inconsistency needs to be considered in order to effectively address and mitigate the issue.

Developing Professionalism and Professional Identity Through Unproctored, Flexible Testing.

The medical education community has devoted a great deal of attention to the development of professionalism in trainees within the context of clinical training-particularly regarding trainees' handling of ethical dilemmas related to clinical care. The community, however, knows comparatively less about the development of professional behavior in medical students during the preclerkship years. In medical schools with flexible testing, students take quizzes or examinations in an unproctored setting at a time of their choosing-as long as it falls within a specified window of time. Unproctored, flexible testing offers students early opportunities to develop appropriate professional behavior. In this Perspective, the authors outline different flexible testing models from three institutions-University of Virginia School of Medicine, University of Michigan Medical School, and Icahn School of Medicine at Mount Sinai-all of which offer various levels of testing flexibility in relation to time and location. The authors' experiences with these models suggest that preclinical medical students' early development of professional behavior requires scaffolding by faculty and staff. Scaffolding involves setting clear, specific expectations for students (often through the form of an honor code), as well as active engagement and discussion with learners about the expectations and procedures for self-regulation in the academic environment.

Does Reducing Clerkship Lengths by 25% Affect Medical Student Performance and Perceptions?

PURPOSE: Transforming a medical school curriculum wherein students enter clerkships earlier could result in two cohorts in clerkships simultaneously during the transition. To avoid overlapping cohorts at the University of Michigan Medical School, the length of all required clerkships was decreased by 25% during the 2016-2017 academic year, without instituting other systematic structural changes. The authors hypothe sized that the reduction in clerkship duration would result in decreases in student perfor mance and changes in student perceptions. METHOD: One-way analyses of variance and Tukey post hoc tests were used to compare the 2016-2017 shortened clerkship cohort with the preceding traditional clerkship cohorts (2014-2015 and 2015-2016) on the following student outcomes: National Board of Medical Examiners (NBME) subject exam scores, year-end clinical skills exam scores, evaluation of clerkships, perceived stress, resiliency, well-being, and perception of the learning environment. RESULTS: There were no significant differences in performance on NBME subject exams between the shortened clerkship cohort and the 2015-2016 traditional cohort, but scores declined significantly over the three years for one exam. Perceptions of clerkship quality improved for three shortened clerkships; there were no significant declines. Learning environment perceptions were not worse for the shortened clerkships. There were no significant differences in performance on the clinical skills exam or in perceived stress, resiliency, and well-being. CONCLUSIONS: The optimal clerkship duration is a matter of strong opinion, supported by few empirical data. These results provide some evidence that accelerating clinical education may, for the studied outcomes, be feasible.

Using a Modified A3 Lean Framework to Identify Ways to Increase Students' Reporting of Mistreatment Behaviors.

PROBLEM: The proportion of students who experience mistreatment is significantly higher than the proportion of students who report mistreatment. Identifying ways to improve students' reporting of these incidents is one strategy for increasing opportunities to achieve resolution and prevent future occurrences. APPROACH: The authors applied a modified A3 Lean framework to examine medical student reporting of mistreatment behaviors at the University of Michigan Medical School (UMMS) in 2013-2016. The A3 Lean framework is a stepwise approach that involves outlining the background to establish the context of the problem, describing the current condition, identifying the goal or desired outcome, analyzing causes of the problem, providing proposed countermeasures for improvement, and creating follow-up plans. The authors identified three reasons for the difference between students' experiences and reporting of mistreatment and developed five countermeasures/action plan items to address this difference. OUTCOMES: The proportion of students reporting mistreatment at UMMS increased 21.4% between 2013 and 2016. Compared with 2013, more students in 2016 indicated not reporting because the incident did not seem important enough or because they resolved the issue on their own. NEXT STEPS: The authors have enlisted the support of the health system's human resources department and presented the inaugural grand rounds on improving the learning environment in 2016. Among other things, they are also partnering with this team to add questions about student mistreatment and civility to the annual employee engagement survey distributed to all 20,000 employees.

The influence of MCAT and GPA preadmission academic metrics on interview scores.

Medical school admissions interviews are used to assess applicants' nonacademic characteristics as advocated by the Association of American Medical Colleges' Advancing Holistic Review Initiative. The objective of this study is to determine whether academic metrics continue to significantly influence interviewers' scores in holistic processes by blinding interviewers to applicants' undergraduate grade point averages (uGPA) and Medical College Admission Test (MCAT). This study examines academic and demographic predictors of interview scores for two applicant cohorts at the University of Michigan Medical School. In 2012, interviewers were provided applicants' uGPA and MCAT scores; in 2013, these academic metrics were withheld from interviewers' files. Hierarchical regression analysis was conducted to examine the influence of academic and demographic variables on overall cohort interview scores. When interviewers were provided uGPA and MCAT scores, academic metrics explained more variation in interview scores (7.9%) than when interviewers were blinded to these metrics (4.1%). Further analysis showed a statistically significant interaction between cohort and uGPA, indicating that the association between uGPA and interview scores was significantly stronger for the 2012 unblinded cohort compared to the 2013 blinded cohort (ß = .573, P < .05). By contrast, MCAT scores had no interactive effects on interviewer scores. While MCAT scores accounted for some variation in interview scores for both cohorts, only access to uGPA significantly influenced interviewers' scores when looking at interaction effects. Withholding academic metrics from interviewers' files may promote assessment of nonacademic characteristics independently from academic metrics.

Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial.

OBJECTIVES: To assess advanced communication skills among second-year medical students exposed either to a computer simulation (MPathic-VR) featuring virtual humans, or to a multimedia computer-based learning module, and to understand each group's experiences and learning preferences. METHODS: A single-blinded, mixed methods, randomized, multisite trial compared MPathic-VR (N=210) to computer-based learning (N=211). Primary outcomes: communication scores during repeat interactions with MPathic-VR's intercultural and interprofessional communication scenarios and scores on a subsequent advanced communication skills objective structured clinical examination (OSCE). Multivariate analysis of variance was used to compare outcomes. SECONDARY OUTCOMES: student attitude surveys and qualitative assessments of their experiences with MPathic-VR or computer-based learning. RESULTS: MPathic-VR-trained students improved their intercultural and interprofessional communication performance between their first and second interactions with each scenario. They also achieved significantly higher composite scores on the OSCE than computer-based learning-trained students. Attitudes and experiences were more positive among students trained with MPathic-VR, who valued its providing immediate feedback, teaching nonverbal communication skills, and preparing them for emotion-charged patient encounters. CONCLUSIONS: MPathic-VR was effective in training advanced communication skills and in enabling knowledge transfer into a more realistic clinical situation. PRACTICE IMPLICATIONS: MPathic-VR's virtual human simulation offers an effective and engaging means of advanced communication training.

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education.

Change is ubiquitous in health care, making continuous adaptation necessary for clinicians to provide the best possible care to their patients. The authors propose that developing the capabilities of a Master Adaptive Learner will provide future physicians with strategies for learning in the health care environment and for managing change more effectively. The concept of a Master Adaptive Learner describes a metacognitive approach to learning based on self-regulation that can foster the development and use of adaptive expertise in practice. The authors describe a conceptual literature-based model for a Master Adaptive Learner that provides a shared language to facilitate exploration and conversation about both successes and struggles during the learning process.

When students struggle with gross anatomy and histology: A strategy for monitoring, reviewing, and promoting student academic success in an integrated preclinical medical curriculum.

Gross anatomy and histology are now often taught as parts of an integrated medical or dental curriculum. Although this puts these foundational basic sciences into a wider educational context, students may not fully appreciate their importance as essential components of their medical education and may not develop a sufficient level of competency, as they are not stand-alone courses. The early identification of medical or dental students who struggle with anatomy or histology and the facilitation of adequate didactic support constitute a significant problem in an integrated curriculum. The timely intervention by an academic review board in combination with an individualized faculty-mediated counseling and remediation process may provide an effective solution to this problem.

Developing a professional pathway in health equity to facilitate curricular transformation at the University of Michigan Medical School.

PROBLEM: Medical schools are challenged to realign curricula to address society's needs in a rapidly changing environment, and to support new instruction and assessment methods that require substantial faculty time. APPROACH: In 2010, the University of Michigan Medical school began planning the Global Health and Disparities Path of Excellence (GHD Path), an optional co-curriculum for students interested in health disparities, with explicit goals to (1) draw attention to the school's social mission; (2) test new, faculty-intensive methods of learning and assessment for all students; and (3) serve as a template for additional co-curricular paths. OUTCOMES: Intended outcomes of the program include enhancing students' competency in leadership related to ameliorating health disparities and the study institution's ability to plan feasible and effective schoolwide reforms in self-directed learning, faculty advising systems, narrative-based feedback for goal setting, Web-based student portfolios, and additional Paths of Excellence. NEXT STEPS: During academic year 2013-2014, the GHD Path is adding more community-based experiences. The faculty development and support model will be streamlined to decrease resources required for program development while retaining key features of the advising system. Lessons from the GHD Path are central to planning schoolwide reform of instructional methods, faculty advising, and student portfolios. The use of a small-scale program to pilot new ideas to inform longer-term, larger-scale changes at our institution might prove useful to other schools striving to meet societal needs while implementing innovative methods of instruction and assessment.

The promise of competency-based education in the health professions for improving global health.

Competency-based education (CBE) provides a useful alternative to time-based models for preparing health professionals and constructing educational programs. We describe the concept of 'competence' and 'competencies' as well as the critical curricular implications that derive from a focus on 'competence' rather than 'time'. These implications include: defining educational outcomes, developing individualized learning pathways, setting standards, and the centrality of valid assessment so as to reflect stakeholder priorities. We also highlight four challenges to implementing CBE: identifying the health needs of the community, defining competencies, developing self-regulated and flexible learning options, and assessing learners for competence. While CBE has been a prominent focus of educational reform in resource-rich countries, we believe it has even more potential to align educational programs with health system priorities in more resource-limited settings. Because CBE begins with a careful consideration of the competencies desired in the health professional workforce to address health care priorities, it provides a vehicle for integrating the health needs of the country with the values of the profession.

Competence in patient safety: a multifaceted experiential educational intervention for resident physicians.

BACKGROUND: The need to provide efficient, effective, and safe patient care is of paramount importance. However, most physicians receive little or no formal training to prepare them to address patient safety challenges within their clinical practice. METHODS: We describe a comprehensive Patient Safety Learning Program (PSLP) for internal medicine and medicine-pediatrics residents. The curriculum is designed to teach residents key concepts of patient safety and provided opportunities to apply these concepts in the "real" world in an effort to positively transform patient care. Residents were assigned to faculty expert-led teams and worked longitudinally to identify and address patient safety conditions and problems. The PSLP was assessed by using multiple methods. RESULTS: Resident team-based projects resulted in changes in several patient care processes, with the potential to improve clinical outcomes. However, faculty evaluations of residents were lower for the Patient Safety Improvement Project rotation than for other rotations. Comments on "unsatisfactory" evaluations noted lack of teamwork, project participation, and/or responsiveness to faculty communication. Participation in the PSLP did not change resident or faculty attitudes toward patient safety, as measured by a comprehensive survey, although there was a slight increase in comfort with discussing medical errors. CONCLUSIONS: Development of the PSLP was intended to create a supportive environment to enhance resident education and involve residents in patient safety initiatives, but it produced lower faculty evaluations of resident for communication and professionalism and did not have the intended positive effect on resident or faculty attitudes about patient safety. Further research is needed to design or refine interventions that will develop more proactive resident learners and shift the culture to a focus on patient safety.

Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.

Patient safety (PS) and quality improvement (QI) are among the highest priorities for all health systems. Resident physicians are often at the front lines of providing care for patients. In many instances, however, QI and PS initiatives exclude trainees. By aligning the goals of the health system with those of the residency program to engage residents in QI and PS projects, there is a unique opportunity to fulfill both a corporate and educational mission to improve patient care. Here, the authors briefly describe one residency program's educational curriculum to provide foundational knowledge in QI and PS to all its trainees and highlight a resident team-based project that applied principles of lean thinking to evaluate the process of responding to an in-hospital cardiopulmonary arrest. This approach provided residents with a practical experience but also presented an opportunity for trainees to align with the health system's approach to improving quality and safety.