From skillful to empathic: evaluating shifts in medical students' perceptions of surgeons through a combined patient as teacher and arts-based reflection program.

Introduction: The purpose of this study was to identify whether the incorporation of a combined Patient as teacher (PAT) and arts-based reflection (ABR) program during a surgical clerkship rotation could influence more humanistic perceptions of surgeons, using an innovative evaluation approach. Methods: A novel, single question evaluation tool was created. Third year medical-students were asked to "list the top 5 attributes of a surgeon, in order of perceived importance" both before and after their surgical clerkship rotations and participation in the PAT/ABR program. Attributes identified by students were coded as either "humanistic" or "non-humanistic," which were then analyzed using generalized linear regression models under a Bayesian framework. Results: After participation in the PAT/ABR program, the predicted probability of students ranking a humanistic characteristic as the most important attribute of a surgeon had increased by 17%, and the predicted probability of students ranking a humanistic characteristic amongst their top three attributes for a surgeon had increased by 21%. Conclusion: This innovative evaluative method suggested the success of a combined PAT/ABR program in encouraging a humanistic perspective of surgery and this approach could potentially be explored to evaluate other humanistic education initiatives.

Introduction: L'objectif de cette étude était de déterminer si l'introduction d'une nouvelle approche d'évaluation associant la participation de Patients comme enseignants (PCE) à une Réflexion basée sur les arts (RBA) dans un stage d'externat en chirurgie permettait de mieux percevoir les qualités humanistes chez les chirurgiens. Méthodes: Un nouvel outil d'évaluation à question unique a été créé. Des étudiants en troisième année de médecine ont été invités à ''énumérer les cinq principaux attributs d'un chirurgien, par ordre d'importance perçue'', avant et après leur stage d'externat en chirurgie et le programme PCE/RBA. Les attributs identifiés par les étudiants ont été codés comme « humanistes ¼ ou « non humanistes ¼, puis analysés à l'aide de modèles de régression linéaire généralisée dans un cadre bayésien. Résultats: Après leur participation au programme PCE/RBA, la probabilité prédite moyenne que les étudiants classent un trait humaniste comme l'attribut le plus important d'un chirurgien a augmenté de 17 %, et la probabilité prédite que les étudiants classent un trait humaniste parmi les trois premiers attributs d'un chirurgien a augmenté de 21 %. Conclusion: Cette méthode d'évaluation innovante porte à croire que le programme PCE/RBA réussit en effet à favoriser une vision humaniste de la chirurgie. Cette approche peut être explorée pour évaluer d'autres activités de formation axées sur l'humanisme.

Educational exposures associated with preclinical medical student interest in pursuing surgical residency: Longitudinal mixed-methods study with narrative evaluation.

Introduction: Pre-clerkship medical students rely on various educational experiences to decide on the residency they would like to pursue. We conducted a longitudinal mixed-methods study to identify educational experiences in pre-clerkship that are associated with an interest in pursuing surgery. Methods: Pre-clerkship medical students were invited to complete an initial survey regarding their interest in surgery and educational exposures. After 10 months, a follow-up survey was sent to identify changes in their interest and the role of educational experiences they may have had in the interim. Univariate regression was used to determine associations, and thematic analysis was done. Results: Data from 218 pre-clerkship students showed that shadowing (OR = 2.7), participation in technical workshops (OR = 5.1), having a mentor (OR = 4.6) and conducting surgical research (OR = 4.6) were associated with an interest in pursuing surgery. From the students with follow-up data, thematic analysis showed that 94 %, 89 %, and 81 % of students found shadowing, research, and mentorship, respectively, as influential in the decision of pursuing a surgical specialty, respectively. Conclusions: Shadowing and mentorship were important factors for students in the decision-making process in pursuing surgery. Identifying high-yield educational experiences-for students to determine if one wants to pursue a surgical specialty is important for educators in curriculum design for resource allocation. Key message: We describe a longitudinal mixed-methods study to determine the role of early educational exposures which influence a medical student's decision to pursue a surgical specialty. Shadowing, technical skills workshops, surgical mentorship, involvement in surgical research, play an important role for student decisions.

Toward 'seeing' critically: a Bayesian analysis of the impacts of a critical pedagogy.

Critical reflection supports enactment of the social roles of care, like collaboration and advocacy. We require evidence that links critical teaching approaches to future critically reflective practice. We thus asked: does a theory-informed approach to teaching critical reflection influence what learners talk about (i.e. topics of discussion) and how they talk (i.e. whether they talk in critically reflective ways) during subsequent learning experiences? Pre-clinical students (n = 75) were randomized into control and intervention conditions (8 groups each, of up to 5 interprofessional students). Participants completed an online Social Determinants of Health (SDoH) module, followed by either: a SDoH discussion (control) or critically reflective dialogue (intervention). Participants then experienced a common learning session (homecare curriculum and debrief) as outcome assessment, and another similar session one-week later. Blinded coders coded transcripts for what (topics) was said and how (critically reflective or not). We constructed Bayesian regression models for the probability of meaning units (unique utterances) being coded as particular what codes and as critically reflective or not (how). Groups exposed to the intervention were more likely, in a subsequent learning experience, to talk in a critically reflective manner (how) (0.096 [0.04, 0.15]) about similar content (no meaningful differences in what was said). This difference waned at one-week follow up. We showed experimentally that a particular critical pedagogical approach can make learners' subsequent talk, ways of seeing, more critically reflective even when talking about similar topics. This study offers the field important new options for studying historically challenging-to-evaluate impacts and supports theoretical assertions about the potential of critical pedagogies.

Visual art-based training in undergraduate medical education: A systematic review.

BACKGROUND: Visual art has been increasingly incorporated into medical education and has been shown to enhance important competencies, such as empathy. However, limited evidence on effective visual art program design and evaluation processes remain. This systematic review examines the format, content, and espoused outcomes of visual art-based training programs in undergraduate medical education. METHODS: A comprehensive literature search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ProQuestERIC on undergraduate medical education and visual arts retrieved 1703 articles published from 2014 to 2020. After reviewing inclusion and exclusion criteria, 23 articles were chosen for full review and synthesis. RESULTS: Program format and content varied, ranging from 1-day specific competency focused programs to well-structured comprehensive 6-12-week programs. 6 areas of program foci were identified: observation skills, empathy, tolerance to uncertainty, cultural sensitivity, team building and collaboration, and wellness and resiliency. Although several programs used validated measures to assess skills acquisition, they seldom addressed long-term outcomes. CONCLUSIONS: Our findings indicate that visual art-based education hold a promise to enhance important competencies in medical education, particularly empathy. Clinical observation, in particular, had the strongest evidence of its effectiveness compared to the other competencies. Future programs incorporating visual arts will benefit from a longitudinal (greater than 6 weeks) program which incorporates guided artworks, reflection exercises, and a group discussion to provide a stronger foundation for the development of core competencies. We propose using validated scales to measure outcomes in future studies and follow-up with participants to better assess Kirkpatrick Level 3 and 4 outcomes.

Patients as teachers and arts-based reflection in surgical clerkship: A preliminary exploration.

BACKGROUND: Involving patients in medical education as teachers is not a novel approach, yet it has not been widely adopted by undergraduate surgical curricula in Canada. The Patients as Teachers initiative in surgery (PAT) program, with an arts-based reflection assignment, was developed for surgical clerks with the goals of emphasizing patient-centredness in surgical practice, humanistic aspects of medicine, and to counterbalance the commonplace emphasis on technical competency in surgery. METHODS: Qualitative data was collected exploring the question: What was the experience and impact of the PAT program on patient teachers and students? Patient teachers (n = 5) were invited to participate in one-on-one interviews and students (n = 46) were invited to participate in focus groups at the end of the program. RESULTS: Findings converged around two main themes: what students/patient teachers valued about the PAT program and what they perceived was learned. While patient teachers felt a sense of emotional healing and appreciated a chance to contribute to medical education, students valued having protected time to learn in depth from the patient teachers. Students also begrudgingly came to appreciate the arts-based reflection assignment. CONCLUSION: By bringing patient voice to the forefront and encouraging reflection, the PAT program emphasized to students the compassionate and humanistic side of surgical care. Future studies could examine the mechanisms by which learning occurs and long-term impacts.

Humanistic education in surgery: a "patient as teacher" program for surgical clerkship.

Summary: Surgeons are frequently perceived by medical students to be uncompassionate, resolute and individualistic. Surgical education often prioritizes teaching and learning approaches that perpetuate these perceptions. In other specialties, engaging patients in education has shown promise in refocusing attention from the technical and procedural aspects of care toward the humanistic and social aspects. Despite proven favourable outcomes for both patients and students in many clinical areas, a "patient as teacher" approach to surgical education has yet to be adopted widely in Canada. A patient as teacher program was developed for surgical clerks at the University of Toronto with the goal of emphasizing the humanity of the patient, the psychosocial impact of a surgical diagnosis of breast cancer on patients and their families, and the social and humanistic roles for surgeons in providing patient-centred care. We report on the program's development process and pilot session.

Beyond empathy: a qualitative exploration of arts and humanities in pre-professional (baccalaureate) health education.

For nearly four decades, researchers have explored the integration of arts and humanities content into health professions education (HPE). However, enduring controversies regarding the purpose, efficacy, and implementation of humanities initiatives suggest that the timing and context of trainees' exposure to such content is a key, but seldom considered, factor. To better understand the affordances of introducing humanities-based health curriculum prior to the HPE admissions gateway, we conducted a qualitative instrumental case study with participants from Canada's first Health Humanities baccalaureate program. Fully anonymized transcripts from semi-structured interviews (n = 11) and focus groups (n = 14) underwent an open-coding procedure for thematic narrative analysis to reveal three major temporal domains of described experience (i.e., prior to, during, and following their participation in a 12-week semester-long "Introduction to Health Humanities" course). Our findings demonstrate that perceptions of arts- and humanities content in health education are generated well in advance of HPE admission. Among other findings, we define a new concept-epistemological multicompetence-to describe participants' emergent capability to toggle between (and advocate for the role of) multiple disciplines, arts and humanities particularly, in health-related teaching and learning at the pre-professional level. Improved coordination of baccalaureate and HPE curricula may therefore enhance the development of capabilities associated with arts and humanities, including: epistemological multicompetence, aesthetic sensibility, and other sought-after qualities in HPE candidates. In conclusion, attending to the pre-professional admissions gateway presents a new, capabilities-driven approach to enhancing both the implementation and critical understanding of arts and humanities' purpose, role, and effects across the "life course" of health professions education.

Critically reflective practice and its sources: A qualitative exploration.

CONTEXT: Critical reflection may improve health professionals' performance of the social roles of care (eg collaboration) in indeterminate zones of practice that are ambiguous, unique, unstable or value-conflicted. Research must explore critical reflection in practice and how it is developed. In this study, we explored what critical reflection consisted of in a context known for indeterminacy, and to what sources participants attributed their critically reflective insights and approaches. METHODS: The study context was the interface between health care and education for children with chronic conditions or disabilities necessitating health-related recommendations and supports (eg accommodations or equipment) at school. We conducted a secondary analysis of 42 interview transcripts from an institutional ethnographic study involving health professionals, school-based educators and parents of children with chronic conditions or disabilities. We coded all transcripts for instances of critical reflection, moments that seemed to lack but could benefit from critical reflection, and participant-attributed sources of critically reflective insights. RESULTS: Critically reflective practice involved getting to know the other, valuing and leveraging different forms and sources of knowledge, identifying and communicating workarounds (ie strategies to circumvent imperfect systems), seeing inequities, and advocating as collaborators, not adversaries. Participants invariably attributed critically reflective insights to personal experiences such as former careers or close personal relationships. CONCLUSIONS: This study shows that personal experiences and connections inspire critically reflective views, and that being critically reflective is not a binary trait possessed (or not) by individuals. It is learnable through personally meaningful experiences. Health professions education could aim to preserve philosophical space for personal experience as a source of learning and integrate evidence-informed approaches to foster critically reflective practice.

'There shouldn't be anything wrong with not knowing': epistemologies in simulation.

CONTEXT: Medical education embraces simulation-based education (SBE). However, key SBE features purported to support learning, such as learner safety and learning through experience and error, may not align with the dominant culture of medicine, in which portraying confidence and certainty about one's knowledge prevails. Misaligned conceptions about knowledge and learning may produce unintended negative effects, including the suboptimal implementation of SBE, which could consequently compromise SBE and its outcomes. METHODS: To uncover the epistemological beliefs of students experiencing SBE, we conducted a theory-informed analysis of interviews with 24 pre-clerkship medical students following their participation in an SBE training study. Our analysis borrowed from coding methods common in constructivist grounded theory and used Hofer and Pintrich's four dimensions of epistemology as sensitising concepts. RESULTS: Participants subscribed to a dominant view of knowledge as consisting of concrete facts, derived from external sources. By contrast, they described but did not prioritise a conception of building their own knowledge through different learning experiences. Participants positioned experts (i.e. teaching faculty members) as the ultimate knowledge validators through their presence and feedback. Participants also noted that faculty staff could counter medicine's pressures to perform with certainty and confidence at all times by instead embodying and modelling an authentic appreciation of learning through experiences, errors and discovery. CONCLUSIONS: Medicine's tendency to idealise the objective pursuit of singular truths may compromise the purported culture of SBE as a space for learning many wide-ranging aspects of medicine, including how and when to innovate and deviate from norms. Explicit attempts to bridge the epistemological beliefs of medicine and SBE may better enable the realisation of safe experiential learning. Faculty members are positioned to play key roles in enabling this bridging.

Clinician, student and faculty perspectives on the audiology-industry interface: implications for ethics education.

Objective: Supporting audiologists to work ethically with industry requires theory-building research. This study sought to answer: How do audiologists view their relationship with industry in terms of ethical implications? What do audiologists do when faced with ethical tensions? How do social and systemic structures influence these views and actions? Design: A constructivist grounded theory study was conducted using semi-structured interviews of clinicians, students and faculty. Study sample: A purposive sample of 19 Canadian and American audiologists was recruited with representation across clinical, academic, educational and industry work settings. Theoretical sampling of grey literature occurred alongside audiologist sampling. Interpretations were informed by the concepts of ethical tensions as ethical uncertainty, dilemmas and distress. Results: Findings identified the audiology-industry relationship as symbiotic but not wholly positive. A range of responses included denying ethical tensions to avoiding any industry interactions altogether. Several of our participants who had experienced ethical distress quit their jobs to resolve the distress. Systemic influences included the economy, professional autonomy and the hidden curriculum. Conclusions: In direct response to our findings, the authors suggest a move to include virtues-based practice, an explicit curriculum for learning ethical industry relations, theoretically-aligned ethics education approaches and systemic and structural change.