Characterization of Distinctive Teaching Practices in Longitudinal Integrated Clerkships: Perspectives From Students and Faculty.

Phenomenon: Longitudinal integrated clerkships (LICs) are novel curricula that place medical students in long-term learning and coaching relationships with faculty and require adaptation of teaching practices on the behalf of faculty to maximize learning outcomes. An understanding of how teaching in an LIC model differs from teaching trainees in more traditional models is critical to ensuring curricular innovation success through faculty development. Approach: A qualitative approach was used to describe the teaching practices of faculty and learning experiences of student participants in longitudinal integrated clerkships in different clinical and community settings. Forty-five faculty and 20 students participated in focus groups. Thematic analysis of focus group data was used to identify differences and similarities between groups, sites, and specialties. Findings: Two groupings of themes emerged in thematic analysis: (1) precepting strategies distinctive to the longitudinal integrated clerkship model and (2) precepting strategies enhanced when employed in the LIC model. Distinct to the LIC model, preceptors and students described the importance of understanding the curricular structure and supporting students in longitudinal care of patients. Enhanced in the LIC model are the strategies of relationship-based teaching, support of autonomy, feedback, and support of longitudinal growth in skills. Insights: Students and faculty across LIC sites were broadly aligned in their opinions of best practices for teaching in an LIC model. The longitudinal relationship between student and faculty in an LIC distinguishes this model from traditional block rotations and a distinctive approach to successful teaching is demonstrated. Preceptors use time afforded to build trusting relationships with students, which created opportunity for novel teaching approaches and enhanced otherwise effective teaching strategies. A focus on orientation to the curricular model and support of longitudinal relationships with patients may serve as an anchor for faculty development efforts in the development of an LIC.

Preliminary Workforce Outcomes of an Urban Longitudinal Integrated Clerkship.

PURPOSE: The authors examined whether students participating in an urban longitudinal integrated clerkship (LIC) with a curriculum focused on care for underserved populations have a sustained commitment to urban underserved care through residency training and into practice. METHOD: This mixed-methods study collected data from medical student application essays to the Denver Health LIC (DH-LIC), end-of-course surveys, residency match outcomes, and postgraduation surveys annually for academic years 2014 to 2022. The authors analyzed students' responses to the surveys on interest in working with underserved patients, understanding the rewards and challenges of working in safety net institutions, working in the community to improve health, and working at DH. The authors qualitatively coded the 70 application essays of all selected students using summative content analysis. RESULTS: Seventy DH-LIC students were compared with 1,450 medical students between 2014 and 2022. Qualitative analysis of LIC application essays revealed 3 themes: interest in working with underserved populations, work experience with underserved populations, and personal experience with medical vulnerability. Fifty-seven DH-LIC participants (81.4%) expressed high levels of career interest in working with underserved populations, 45 (64.3%) had high levels of work experience with underserved populations, and 18 (25.7%) expressed high levels of personal experience. Graduates of the DH-LIC program demonstrated a high degree of continuing interest in practicing in urban underserved settings throughout medical school and postgraduate training. Ten graduates (71.4%) in practice work in urban underserved settings. Participants reported a high or very high level of interest and commitment to working with underserved populations (96.7%-100%), understanding the safety net health care system (91.7%-98.6%), and working in communities (95.0%-100%) at all time points studied. CONCLUSIONS: Early data indicate high rates of graduates working in urban underserved settings. These preliminary outcomes suggest the LIC may support the development of a committed workforce for urban underserved communities.

Designing a Shortened Preclinical Basic Science Curriculum: Expert-Derived Recommendations.

PURPOSE: To generate an expert-derived list of recommendations for how medical schools should approach decisions about the placement of basic science topics within shortened preclinical curricula, which allow for early clinical immersion. METHOD: A modified Delphi process was used to develop consensus on recommendations (March-November 2021). The authors performed semistructured interviews with national undergraduate medical education (UME) experts from institutions that previously underwent curricular reforms involving shortened preclinical curricula to elicit perspectives on how decisions were made at their institutions. The authors condensed the findings into a preliminary list of recommendations and distributed this list in 2 survey rounds to a larger group of national UME experts (from institutions that previously underwent curricular reforms or held positions of authority within national UME organizations) to gauge their level of agreement with each recommendation. Recommendations were revised based on participant comments, and those with at least 70% somewhat or strong agreement after the second survey were included in the final comprehensive list of recommendations. RESULTS: Interviews were conducted with 9 participants and resulted in 31 preliminary recommendations that were then sent via survey to the 40 recruited participants. Seventeen/40 (42.5%) participants completed the first survey, after which 3 recommendations were removed, 5 were added, and 5 were revised based on comments-resulting in 33 recommendations. Twenty-two/38 (57.9%) participants responded to the second survey, after which all 33 recommendations met inclusion criteria. The authors removed 3 recommendations that did not directly address the curriculum reform process and consolidated the final 30 recommendations into 5 succinct, actionable takeaways. CONCLUSIONS: This study generated 30 recommendations (summarized by the authors in 5 succinct takeaways) for medical schools designing a shortened preclinical basic science curriculum. These recommendations reinforce the importance of vertically integrating basic science instruction with explicit clinical relevance into all curricular phases.

Pediatric Residents' Experiences With High-Value Care at an Academic Children's Hospital.

BACKGROUND: The Accreditation Council for Graduate Medical Education mandates residents incorporate cost considerations into patient care. However, resident experiences with high-value care (HVC) in the clinical setting have not been well described. OBJECTIVE: To explore pediatric residents' experiences with HVC and its facilitators and barriers. METHODS: We performed a qualitative study with a grounded theory epistemology of pediatric residents recruited by email at a large academic children's hospital. We conducted focus groups (n=3) and interviews (n=7) between February and September 2020 using a semi-structured guide. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into thematic categories. Sampling continued until saturation was reached. RESULTS: Twenty-two residents participated. Residents' value-based health care decisions occurred in a complex learning environment. Due to limited experience, residents feared missing diagnoses, which contributed to perceived overtesting. Resident autonomy, with valuable experiential learning, supported and hindered HVC. Informal teaching occurred through patient care discussions; however, cost information was lacking. Practice of HVC varied by clinical setting with greater challenges on high acuity and subspecialty services. For children with medical complexity, identifying family concerns and goals of care improved value. Family experience/demands influenced resident health care decisions, contributing to high- and low-value care. Effective collaboration among health care team members was crucial; residents often felt pressured following perceived low-value recommendations from consultants. CONCLUSIONS: Resident HVC learning and practice is influenced by multiple factors in a complex clinical learning environment.

Beyond Nutrition Knowledge and Tools-What Do Pediatric Providers Really Need?

Nutrition counseling continues to be a concern for pediatric providers. This study aimed to extend the understanding of the perceptions of pediatric providers regarding nutrition care. Individual semi-structured qualitative interviews were conducted using a purposive sampling technique. Interviews were conducted in-person or via telephone, recorded, and transcribed. Seven themes emerged from the data and these can be used as a "how to" for medical educators. Based on the experiences and perspectives of the pediatric providers in our study, we are moving forward with the systematic development of a curriculum to improve nutrition care and counseling in pediatrics.

A longitudinal career-focused block for third-year pediatrics residents.

BACKGROUND: The traditional 1-month training blocks in pediatrics may fail to provide sufficient exposure to develop the knowledge, skills, and attitudes residents need for practice and may not be conducive to mentoring relationships with faculty and continuity with patients. INTERVENTION: We created a 4-month career-focused experience (CFE) for third-year residents. The CFE included block time and longitudinal experiences in different content areas related to residents' choice of urban and rural primary care, hospitalist medicine, or subspecialty care (prefellowship). Content was informed by graduate surveys, focus groups with primary care pediatricians and hospitalists, and interviews with fellowship directors. Outcomes were assessed via before and after surveys of residents' attitudes and skills, assessment of skills with an objective structured clinical examination (OSCE), and interviews with residents and mentors. RESULTS: Twenty-three of 49 third-year residents took part in the first 2 years of CFE. Two residents dropped out, leaving 21 who completed the 4-month experience (9 in primary care, 2 in hospitalist medicine, and 10 in a subspecialty). Residents reported improvement in their clinical skills, increased satisfaction with faculty mentoring and evaluation, and the ability to focus on what was important to their careers. OSCE performance did not differ between residents who completed the CFE and those who did not. Administrative burden was high. CONCLUSIONS: Four-month career-focused training for pediatrics residents is feasible and may be effective in meeting part of the new requirement for 6 months of career-focused training during pediatrics residency.