Psychological safety and accountability in longitudinal integrated clerkships: a dual institution qualitative study.

BACKGROUND: Psychological safety and accountability are frameworks to describe relationships in the workplace. Psychological safety is a shared belief by members of a team that it is safe to take interpersonal risks. Accountability refers to being challenged and expected to meet expectations and goals. Psychological safety and accountability are supported by relational trust. Relational continuity is the educational construct underpinning longitudinal integrated clerkships. The workplace constructs of psychological safety and accountability may offer lenses to understand students' educational experiences in longitudinal integrated clerkships. METHODS: We performed a qualitative study of 9 years of longitudinal integrated clerkship graduates from two regionally diverse programs-at Harvard Medical School and the University of North Carolina School of Medicine. We used deductive content analysis to characterize psychological safety and accountability from semi-structured interviews of longitudinal integrated clerkship graduates. RESULTS: Analysis of 20 graduates' interview transcripts reached saturation. We identified 109 discrete excerpts describing psychological safety, accountability, or both. Excerpts with high psychological safety described trusting relationships and safe learning spaces. Low psychological safety included fear and frustration and perceptions of stressful learning environments. Excerpts characterizing high accountability involved increased learning and responsibility toward patients. Low accountability included students not feeling challenged. Graduates' descriptions with both high psychological safety and high accountability characterized optimized learning and performance. CONCLUSIONS: This study used the workplace-based frameworks of psychological safety and accountability to explore qualitatively longitudinal integrated clerkship graduates' experiences as students. Graduates described high and low psychological safety and accountability. Graduates' descriptions of high psychological safety and accountability involved positive learning experiences and responsibility toward patients. The relational lenses of psychological safety and accountability may inform faculty development and future educational research in clinical medical education.

Practical tips for teaching ethics and humanism to medical students.

This article presents the results of a decade's experiment in creating a longitudinal ethics and humanism curriculum for the core clinical year at UNC School of Medicine, North Carolina, United States. This curriculum applies published research on best practices in medical ethics education. Sample comments from course evaluations of the students who have completed this curriculum provide support for its success at achieving its desired learning outcomes. To create a similar ethics curriculum in the core clinical year at other medical schools, there are twelve practical tips:  preparation: read the research on the ethical challenges for medical students; recruit an interdisciplinary teaching team; create cohorts for this aspect of the curriculum that will stay together for the year; grade only with pass/fail; have the students bring the cases from their clinical experiences; feed them if possible, and structure the time together carefully. Use a narrative ethics methodology and introduce alternative methods for student writing and group process. Connect students with literature in medical humanities and bioethics and encourage publication of their narratives. As with any good creation, the whole is more than the sum of its parts, and each campus can adapt these guidelines for their people and programs.

What happy physicians have in common: A qualitative study of workplace perceptions of physicians with low burnout scores.

Introduction: Burnout is a phenomenon in the medical field that adversely affects patient care, physician retention, and physician well-being. The preponderance of burnout research has primarily focused on exploring what parts of medical practice and individual characteristics contribute to burnout. Our research aims to add to the growing body of evidence exploring what physicians who love their work have in common. Methods: Physician participants in this qualitative study were recruited through their local medical society from those who indicated a willingness to share tips for joy in practice. Potential participants were then screened for low probability of burnout using a validated single-item burnout inventory. Nine primarily mid- to late-career physicians engaged in semi-structured interviews and thematic analysis was used to analyze data. Of the interviewed physicians, five were practicing in the primary care specialties of family or internal medicine and four in specialties outside of primary care. Results: Six major themes arose from the nine interviews and included variety in work, a sense of empowerment, connection with patients, visible impact of one's work, feelings of community with coworkers and colleagues, and experiencing a sense of calling. Conclusion: While further research is needed to demonstrate the transferability of the themes from these interviews, an asset-rooted approach to physician wellness is a direction for research and intervention that deserves further attention. Focusing only on alleviating the factors that contribute to burnout is a worthy goal, but ignores the necessity of designing training systems and workplaces that are built to foster the elements of medicine that bring joy and fulfillment to practice.

Physician Preceptor Satisfaction and Productivity Across Curricula: A Comparison Between Longitudinal Integrated Clerkships And Traditional Block Rotations.

Phenomenon: Physicians are under intense pressure to improve clinical productivity. High clinical load, limited availability, and decreased clinical efficiency are well-documented barriers to precepting medical students and threaten clinical productivity. In an era of increasing medical student enrollment, these barriers have already led to a decreased availability of clinical teachers and training sites across the United States. Improved preceptor satisfaction could have a great impact on recruitment and retention of medical student preceptors and is likely linked to changes in productivity. Curriculum structure could impact both preceptor productivity and satisfaction. Comparing productivity and satisfaction of physician preceptors teaching in longitudinal integrated clerkships (LICs) to those teaching in traditional block rotations (TBRs), or in both settings (LIC-TBR), could lead to a better understanding of the impact of curriculum structure on preceptor productivity and satisfaction. Approach: Data were collected through a quantitative cross-sectional survey of outpatient physician preceptors in North Carolina in 2017. Preceptor satisfaction and student influence on productivity-related aspects of practice were analyzed with bivariate chi-square statistics and multivariate logistic regression. Findings: Analyses included 338 physician preceptors: 79 LIC (23%), 50 LIC-TBR (15%), and 209 TBR preceptors (62%). LIC preceptors were more likely to indicate being "very satisfied" with precepting than either their LIC-TBR or TBR counterparts. There were no differences in perceived productivity-related aspects of practice across the different curricula, such as patient flow, income, or physician working hours. Logistic regressions controlling for potential confounding variables suggested that those teaching in LICs were almost 3 times more likely to be "very satisfied" relative to those teaching in LIC-TBR and TBR settings and that the negative influence of students on patient flow and physician working hours had an adverse effect on preceptor satisfaction. Insights: Preceptor satisfaction was high overall, though satisfaction was significantly higher among preceptors who teach in LICs. The perceived impact of students on clinical productivity was stable across the different curricula. In an era of increasing need for physician preceptors, the higher satisfaction of those who teach in LICs should be considered in curricular design and for preceptor recruitment and retention.

Cracking the Nut on LCME Standard 8.7: Innovations to Ensure Comparability Across Geographically Distributed Campuses.

Problem: A large state university in the southeastern United States and state Area Health Education Centers (AHEC) collaborated to establish branch campuses to increase clinical capacity for medical student education. Prior to formally becoming branch campuses, two AHEC sites had established innovative curricular structures different than the central campus. These sites worked with the central campus as clinical training sites. Upon becoming formal campuses, their unique clinical experiences were maintained. A third campus established a curricular structure identical to the central campus. Little exists in the literature regarding strategies that ensure comparability yet allow campuses to remain unique and innovative. Intervention: We implemented a balanced matrix organizational structure, well-defined communication plan, and newly developed tool to track comparability. A balanced matrix organization model framed the campus relationships. Adopting this model led to identifying reporting structures, developing multidirectional communication strategies, and the Campus Comparability Tool. Context: The UNC School of Medicine central campus is in Chapel Hill. All 192 students complete basic science course work on central campus. For required clinical rotations, approximately 140 students are assigned to the central campus, which includes rotations in Raleigh or Greensboro. The remaining students are assigned to Asheville (25-30), Charlotte (25-30), or Wilmington (5-7). Chapel Hill and Wilmington follow identical rotation structures, 16 weeks each of (a) combined surgery and adult inpatient experiences; (b) combined obstetrics/gynecology, psychiatry, and inpatient pediatrics; and (c) longitudinal clinical experiences in adult and pediatric medicine. Asheville offers an 8-month longitudinal integrated outpatient experience with discreet inpatient experiences in surgery and adult care. Charlotte offers a 6-month longitudinal integrated experiences and 6 months of block inpatient experiences. Aside from Charlotte and Raleigh, the other sites are urban but surrounded by rural counties. Chapel Hill is 221 miles from Asheville, 141 from Charlotte, and 156 from Wilmington. Outcome: Using the balanced matrix organization, various reporting structures and lines of communication ensured the educational objectives for students were clear on all campuses. The communication strategies facilitated developing consistent evaluation metrics across sites to compare educational experiences. Lessons Learned: The complexities of different healthcare systems becoming regional campuses require deliberate planning and understanding the culture of those sites. Recognizing how size and location of the organization affects communication, the central campus took the lead centralizing functions when appropriate. Adopting uniform educational technology has played an essential role in evaluating the comparability of core educational content on campuses delivering content in very distinct ways.

Training for Future Generations: Innovations in the Medical Education of Physicians in North Carolina.

North Carolina's five medical schools are responding to the changing health care landscape and continued shortage of rural, primary care physicians through curricular innovations. Early indications suggest that these innovations-involving themes of longitudinal training, immersive experiences, practice transformation, and health equity promotion-will lead to a new physician workforce.

The North Carolina Community Preceptor Experience: Third Study of Trends Over 12 Years.

PURPOSE: To measure community-based preceptors' overall satisfaction and motivations, the influence of students on preceptors' practices, and compare with 2005 and 2011 studies. METHOD: North Carolina primary care preceptors across disciplines (physicians, pharmacists, advanced practice nurses, physician assistants) received survey invitations via e-mail, fax, postcard, and/or full paper survey. Most questions in 2017 were the same as questions used in prior years, including satisfaction with precepting, likelihood to continue precepting, perceived influence of teaching students in their practice, and incentives for precepting. A brief survey or phone interview was conducted with 62 nonresponders. Chi-square tests were used to examine differences across discipline groups and to compare group responses over time. RESULTS: Of the 2,786 preceptors contacted, 893 (32.1%) completed questionnaires. Satisfaction (816/890; 91.7%) and likelihood of continuing to precept (778/890; 87.4%) remained unchanged from 2005 and 2011. However, more preceptors reported a negative influence for patient flow (422/888; 47.5%) in 2017 than in 2011 (452/1,266; 35.7%) and 2005 (496/1,379; 36.0%) (P < .0001), and work hours (392/889; 44.1%) in 2017 than in 2011 (416/1,268; 32.8%) and 2005 (463/1,392; 33.3%) (P < .0001). Importance of receiving payment for teaching increased from 32.2% (371/1,152) in 2011 to 46.4% (366/789) in 2017 (P < .0001). CONCLUSIONS: This 2017 survey suggests preceptor satisfaction and likelihood to continue precepting have remained unchanged from prior years. However, increased reporting of negative influence of students on practice and growing value of receiving payment highlight growing concerns about preceptors' time and finances and present a call to action.

Texting Brief Podcasts to Deliver Faculty Development to Community-Based Preceptors in Longitudinal Integrated Clerkships.

Introduction: Longitudinal integrated clerkships (LICs) are an increasingly popular clerkship model that relies heavily on community-based preceptors. The availability of an engaged and prepared community-based faculty is crucial to the success of these programs. Teachers in these programs are often geographically separate from medical school campuses, are engaged in busy practices, and have limited time to devote to faculty development activities. Methods: We created a series of five brief faculty development podcasts directed towards community-based teachers in LICs from three US medical schools. Topics included encouraging continuity, bedside teaching, encouraging student ownership of patients, communicating and managing patient results between clinic days, and choosing the right patients for continuity. The podcasts were sent via a grouped text message just prior to preceptors' morning commute time. Pre- and postsurveys assessed the acceptability and effectiveness of the podcasts. Results: Among the 33 postintervention survey responders, 27 (81.8%) listened to at least three podcasts, 21 (63.6%) found them moderately or very helpful, 23 (69.7%) perceived that the podcasts altered their teaching style, 23 (69.7%) would likely or highly likely listen to further podcasts, and 18 (54.5%) would likely or highly likely recommend the podcasts to colleagues. Discussion: In a cohort of multispecialty faculty teaching in LICs, educational podcasts were well received and perceived by preceptors to impact their teaching style. Texting these podcasts to other community-based preceptors may offer an effective strategy for providing faculty development to busy clinicians.

Graduates' Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study.

PURPOSE: The authors explored affordances that contribute to participants' successful learning in longitudinal integrated clerkships (LICs). METHOD: This dual-institutional, mixed-methods study included electronic surveys and semistructured interviews of LIC graduates who completed their core clinical (third) year of medical school. These LIC graduates took part in LICs at Harvard Medical School from 2004 to 2013 and the University of North Carolina School of Medicine-Asheville campus from 2009 to 2013. The survey questions asked LIC graduates to rate components of LICs that they perceived as contributing to successful learning. A research assistant interviewed a subset of study participants about their learning experiences. The authors analyzed aggregate data quantitatively and performed a qualitative content analysis on interview data. RESULTS: The graduates reported multiple affordances that they perceive contributed to successful learning in their LIC. The most reported components included continuity and relationships with preceptors, patients, place, and peers, along with integration of and flexibility within the curriculum. CONCLUSIONS: As LIC models grow in size and number, and their structures and processes evolve, learners' perceptions of affordances may guide curriculum planning. Further research is needed to investigate to what degree and by what means these affordances support learning in LICs and other models of clinical education.

Preceptor teaching tips in longitudinal clerkships.

BACKGROUND: In longitudinal integrated clerkships (LICs), the continuous preceptor and student relationship over time creates opportunities for more in-depth teaching approaches than shorter preceptorships allow. We identify student perceptions of the most effective teaching practices and develop tips for LIC preceptors. METHODS: The first four third-year medical student classes completing the Asheville LIC of the University of North Carolina School of Medicine (UNC SOM) formed the subject group. Between June and August 2013, a trained research assistant (AS) conducted semi-structured interviews with all 27 UNC SOM Asheville LIC students. Interviews were transcribed and coded by thematic analysis. RESULTS: All 27 (100%) students participated in the interviews. We identified seven main themes of successful precepting practices: enhance teaching; create bring-backs (learning topics to bring back to preceptors); support patient ownership; structure clinic; improve feedback; engage learners; and develop a relationship. These themes were condensed into nine preceptor tips for teaching in LICs. CONCLUSIONS: The longitudinal relationship of preceptor and student in LIC models affords specific, important opportunities for teaching and learning. The concise list of LIC preceptor tips can be used by preceptors to further optimise their teaching in the LIC setting. We identify student perceptions of the most effective teaching practices and develop tips for LIC preceptors.

Academic outcomes of a community-based longitudinal integrated clerkships program.

BACKGROUND: Longitudinal integrated clerkships (LICs) receive recognition internationally as effective, innovative alternatives to traditional block rotations (TBRs) in undergraduate medical education. No studies of LICs in the USA have assessed how students perform on all the standardized exams. AIM: To compare performance on standardized tests of students in the first four years of LICs at the University of North Carolina School of Medicine-Asheville (UNC SOM-Asheville) with students from UNC SOM's Chapel Hill main campus in TBRs. METHODS: LIC and TBR students' previous academic performance was considered using Medical College Admissions Test (MCAT) and United States Medical Licensing Examination (USMLE) Step 1 scores. Step 1 exam tests students' pre-clinical, basic science knowledge. Outcome measures included all eight standardized National Board of Medical Examiners (NBME) Subject Shelf Examinations and USMLE Step 2 Clinical Knowledge (CK) examinations, which are used widely in the US to assess students' progress and as prerequisites to eventual licensure. TBR students were selected using propensity scores to match LIC students. Groups were also compared on the required core clinical conditions documented, and on residency specialty choice. RESULTS: Asheville LIC students earned higher scores on the Step 2 CK examination and the six shelf examinations linked to longitudinal clerkships than the matched TBR students (Step 2 CK exam, Family Medicine and Ambulatory Medicine shelf exams reached statistical significance). LIC students logged greater percentages of core conditions than TBR students and more often chose primary care residencies. CONCLUSIONS: UNC School of Medicine medical students participating in a longitudinal integrated curriculum in a community setting outperformed fellow students who completed a more TBR curriculum within the school's academic medical center. Differences were found in performance on standard tests of clinical knowledge (six NBME exams and Step 2 CK exam), documented breadth of clinical experiences, and likelihood of choosing primary care residency programs.

The third-year longitudinal integrated clerkship at the Asheville campus of the University of North Carolina School of Medicine.

Consumers, health delivery planners, and public officials are calling for patient-centered, primary care-based, cost-effective health care. The Asheville campus of the University of North Carolina School of Medicine has responded to this need by developing a longitudinal integrated clerkship that trains third-year medical students to provide such care.

Satisfaction, motivation, and future of community preceptors: what are the current trends?

PURPOSE: To measure overall satisfaction of community-based preceptors, their anticipated likelihood of continuing to teach, professional satisfaction, influence of having students, motivation for teaching, satisfaction with professional practice, and satisfaction with and value of incentives, and to compare results with those of a similar 2005 statewide survey. METHOD: In 2011, the authors distributed a 25-item survey to all 2,359 community-based primary care preceptors (physicians, pharmacists, advanced practice nurses, physician assistants) served by the North Carolina Area Health Education Centers system's Offices of Regional Primary Care Education. The survey targeted the same items and pool of eligible respondents as did the North Carolina Area Health Education Center 2005 Preceptor Survey. RESULTS: Of 2,359 preceptors contacted, 1,278 (54.2%) completed questionnaires. The data from 2011 did not differ significantly from the 2005 data. In 2011, respondents were satisfied with precepting (91.7%), anticipated continuing to precept for the next five years (88.7%), and were satisfied overall with their professional life (93.7%). Intrinsic reasons (e.g., enjoyment of teaching) remained an important motivation for teaching students. Physicians reported significantly lower overall satisfaction with extrinsic incentives (e.g., monetary compensation) and felt more negativity about the influence of students on their practices. CONCLUSIONS: This study found that preceptors continue to be satisfied with teaching students. Intrinsic reasons remain an important motivation to precept, but monetary compensation may have increasing importance. Physicians responded more negatively than other health provider groups to several questions, suggesting that their needs might be better met by redesigned teaching models.

Family medicine community preceptors: different from other physician specialties?

BACKGROUND AND OBJECTIVES: Few studies address the satisfaction of community preceptors in different specializations. This study compares preceptor satisfaction of family physicians with other physician specialties. METHODS: All 1,221 physician preceptors in a statewide system received surveys by mail. RESULTS: Almost 67% returned questionnaires. The group consisted of 46% family physicians, 22% internists, 20% pediatricians, and 12% physicians in other specialties. The majority reported high levels of satisfaction with precepting (94.4%), incentives (53.3%), and professional life (91.6%). Significantly more family physicians and pediatricians than physicians in other specialties felt that having students had a more negative influence on patient flow (54.4% and 53.5%), and family physicians were more likely to indicate that precepting students increased their working hours. Family physicians more often reported that helping recruit for their specialty was an important factor in their decision to teach (32.8%). Family physicians placed more importance on receiving continuing medical education credit for teaching and less value on academic appointments, and they were also less satisfied with their incomes. CONCLUSIONS: Family medicine community physician preceptors have some differing needs and motivations than other physician specialties. With the increased demand for preceptors, it is important to tailor support to meet individual preceptor needs.

The satisfaction, motivation, and future of community preceptors: the North Carolina experience.

PURPOSE: To measure satisfaction and motivation of community-based preceptors, and to examine differences between degree groups of physicians, pharmacists, advanced-practice nurses (nurse practitioners and certified nurse midwives), and physician assistants. METHOD: In spring 2005, the authors mailed a four-page, 24-item survey to all 2,061 community-based primary care preceptors served by the North Carolina Area Health Education Centers system. The survey measured preceptor satisfaction, likelihood of continuing as a preceptor, influence of having students, motivation for teaching, satisfaction in professional practice, satisfaction with incentives, and value of incentives. RESULTS: Response rate was 69.3%, or 1,428 preceptors. Most preceptors (93.0%) reported high satisfaction with their precepting experience, and 90.9% indicated high likelihood of continuing to precept for the next five years. Almost all preceptors (93.7%) reported they were satisfied with their professional life. Many community preceptors (57.2%) were satisfied with incentives. They placed greater value on the intrinsic reasons for precepting (i.e., enjoyment of teaching) rather than extrinsic rewards (such as no-cost online library resources). Degree groups placed differing values on intrinsic and extrinsic rewards. Physicians reported more negativity about the influence of students and regarding aspects of their professional lives. CONCLUSIONS: Tailoring support to better meet individual degree groups' preferences can maximize resources and may encourage preceptor retention. Special attention to physicians' needs may be warranted to avoid decreased preceptor numbers in this at-risk group. Future studies are needed to determine whether these findings are unique to North Carolina, which has a strong infrastructure to support preceptors.