Struggles and Joys: A Mixed Methods Study of the Artefacts and Reflections in Medical Student Portfolios.

Introduction: Portfolios scaffold reflection on experience so students can plan their learning. To elicit reflection, the learning experiences documented in portfolios must be meaningful. To understand what experiences first- and second-year medical students find meaningful, we studied the patterns in the artefacts chosen for portfolios and their associated written reflections. Methods: This explanatory mixed methods study of a longitudinal dataset of 835 artefacts from 37 medical student' portfolios, identified patterns in artefact types over time. Mixed model logistic regression analysis identified time, student and curriculum factors associated with inclusion of the most common types of artefacts. Thematic analysis of participants' reflections about their artefacts provided insight into their choices. Interpretation of the integrated findings was informed by Transformative Learning (TL) theory. Results: Artefact choices changed over time, influenced by curriculum changes and personal factors. In first year, the most common types of artefacts were Problem Based Learning mechanism diagrams and group photos representing classwork; in second year written assignments and 'selfies' representing social and clinical activities. Themes in the written reflections were Landmarks and Progress, Struggles and Strategies, Connection and Collaboration, and Joyful Memories for Balance. Coursework artefacts and photographic self-portraits represented all levels of transformative learning from across the curriculum. Conclusions: Medical students chose artefacts to represent challenging and/or landmark experiences, balanced by experiences that were joyful or fostered peer connection. Novelty influenced choice. To maximise learning students should draw from all experiences, to promote supported reflection with an advisor. Tasks should be timed to coincide with the introduction of new challenges.

Informed self-assessment during the transition to medical school: a longitudinal narrative study.

OBJECTIVES: To explore how medical students' narratives of informed self-assessment (ISA) change during their first 18 months of study. DESIGN: This longitudinal study used student narratives drawn from qualitative interviews and written reflections during the transition to medical school, to examine changes in ISA. Our analysis was informed by Situated Cognition Theory which recognises the impact and interplay of personal and environmental factors in cognition. SETTING: To study medicine, first year students need to adapt their self-regulated learning in the context of a new peer group, study demands and educational culture. During this adaptation, students need to seek and interpret available cues to inform their self-assessment. PARTICIPANTS: Longitudinal data were collected at five time points over 18 months from a diverse sample of seven first year medical students in an undergraduate medical programme, including 13.5 hours of interviews and 12 written reflections. RESULTS: Before and after starting medical school, the participants' self-assessments were informed by environmental influences (exam results and comparison with peers), and personal influences (fear of failure and anxiety about not belonging). Early uncertainty meant self-assessments were overestimated and underestimated.By the end of first year, an enhanced sense of belonging coincided with less fear of failure, less emphasis on exam performance and reduced competition with peers. Self-assessments became increasingly informed by evidence of clinical skills and knowledge gained related to future professional competence. CONCLUSION: Influences on medical students' ISAs change during the transition to studying medicine. A greater sense of belonging, and evidence of progress towards clinical competence became more important to self-assessment than comparison with peers and exam performance. Our findings reinforce the importance of formative assessments, opportunities to study and socialise with peers and early clinical experiences during first year. These experiences enhance ISA skills during the transition to medical school.

Medical students' self-regulation of learning in a blended learning environment: a systematic scoping review.

BACKGROUND: Medical curricula are constantly evolving in response to the needs of society, accrediting bodies and developments in education and technology. The integration of blended learning modalities has challenged traditional methods of teaching, offering new prospects in the delivery of medical education. The purpose of this review is to explore how medical students adapt their learning behaviours in a Blended Learning environment to become more independent and self-regulated, in addition to highlighting potential avenues to enhance the curriculum and support student learning. METHODS: Using the approach described by Levac et al. (2010), which builds on Arksey and O'Malley's framework, we conducted a literature search of the following databases: MEDLINE (Ovid), ERIC, EBSCO, SCOPUS and Google Scholar, utilising key terms and variants of "medical student', 'self-regulated learning' and 'blended learning'. The search yielded 305 studies which were further charted and screened according to the Joanna Briggs Institute. RESULTS: Forty-four studies were identified and selected for inclusion in this review. After full analysis of these studies, underpinned by Self-regulation theory, five major concepts associated with students' learning behaviours in a Blended Learning environment were identified: Scaffolding of instructional guidance may support self-regulated learning; Self-regulated learning enhances academic performance; Self-regulated Learning improves study habits through resource selection; Blended learning drives student motivation and autonomy; and the Cognitive apprenticeship approach supports Self-regulated learning. CONCLUSION: This review uncovers medical students' learning behaviours within a Blended learning environment which is important to consider for curricular adaptations and student support.

Moral judgement development during medical student clinical training.

BACKGROUND: Whereas experience and cognitive maturity drives moral judgement development in most young adults, medical students show slowing, regression, or segmentation in moral development during their clinical years of training. The aim of this study was to explore the moral development of medical students during clinical training. METHODS: A cross-sectional sample of medical students from three clinical years of training were interviewed in groups or individually at an Australian medical school in 2018. Thematic analysis identified three themes which were then mapped against the stages and dimensions of Self-authorship Theory. RESULTS: Thirty five medical students from years 3-5 participated in 11 interviews and 6 focus groups. Students shared the impacts of their clinical experiences as they identified with their seniors and increasingly understood the clinical context. Their accounts revealed themes of early confusion followed by defensiveness characterised by desensitization and justification. As students approached graduation, some were planning how they would make moral choices in their future practice. These themes were mapped to the stages of self-authorship: External Formulas, Crossroads and Self-authorship. CONCLUSIONS: Medical students recognise, reconcile and understand moral decisions within clinical settings to successfully reach or approach self-authorship. Curriculum and support during clinical training should match and support this progress.

Where are they now? An autism follow-up study.

AIM: To explore the stability of diagnosis and the relationship between behavioural, adaptive and developmental skills in early to middle childhood in children with autism spectrum disorder (ASD). METHODS: Fifty-four children recruited to the study were diagnosed with ASD before 42 months. Outcomes at follow-up after a mean interval of 64 months were measured using the Autism Diagnostic Observation Schedule, Vineland-II adaptive scale and Wechsler Intelligence Scale for Children and parental survey data. Scores before school were compared with follow-up data through descriptive, correlational and multiple regression analyses. RESULTS: ASD was confirmed in all children at follow-up (mean age 10 years). Fifty-eight percent of children were enrolled in a supported educational class or school and 42% were taking a psychotropic medication. Adaptive function improved significantly in 19% of children. Developmental and adaptive behavioural scores before school correlated with cognitive, behaviour and adaptive assessments at follow-up. CONCLUSION: At follow-up, the diagnosis was confirmed in all children. The children showed gains in their adaptive skills but and many required ongoing educational and behavioural support. Early developmental and adaptive assessments reliably predicted later educational support needs, cognitive and adaptive function and are a useful component of a diagnostic assessment.

A paediatric logbook: Millstone or milestone?

Logbooks are ubiquitous in undergraduate and postgraduate medical education. Here, two alumni who are in the early phase of their career, reflect on their experience in their undergraduate paediatric term and how this was shaped by their mandatory paediatric logbook.

Humans and machines: Moving towards a more symbiotic approach to learning clinical reasoning.

Artificial intelligence is a growing phenomenon that is driving major changes to how we deliver healthcare. One of its most significant and challenging contributions is likely to be in diagnosis. Artificial intelligence is challenging the physician's exclusive role in diagnosis and in some areas, its diagnostic accuracy exceeds that of humans. We argue that we urgently need to consider how we will incorporate AI into our teaching of clinical reasoning in the undergraduate curriculum; students need to successfully navigate the benefits and potential issues of new and developing approaches to AI in clinical diagnosis. We offer a pedagogical framework for this challenging change to our curriculum.

Twelve tips for teaching child development and disability to medical students.

Child development is a marker of well-being in childhood and recognition of developmental delay allows timely investigation and intervention for children with developmental disabilities. Despite this, child development and disabilities are not given emphasis in the medical curriculum. This under representation of teaching combined with the stigma associated with disabilities contributes to the sub-optimal health care of people with disabilities. As well as, addressing the stigma of disability a medical undergraduate curriculum should include: the key concepts of child development; the clinical presentation of the most common developmental disabilities; developmental history taking and the infant neurodevelopmental examination. The following twelve tips provide practical advice about how to teach this knowledge and these skills during medical training.

Social disadvantage and developmental diagnosis in pre-schoolers.

AIM: To explore the association between social disadvantage and developmental diagnoses in pre-school children. METHODS: Between 2012 and 2015, 845 pre-school children were assessed by the Child Assessment Team at Campbelltown Hospital. A social worker interviewed 469 families and these children were eligible for inclusion in the study. Autism spectrum disorder (ASD) was confirmed in 290 children. Of those without ASD, 72 did not have global developmental delay (GDD) and were excluded from the study. The remaining 107 children with GDD were used as the comparison group. Social risk factors in the two groups were compared using χ 2 tests. Variables with statistical significance were then entered into a logistic regression. RESULTS: After logistic regression, children with ASD were more likely to be male (odds ratio (OR) 3.1, 95% CI 0.195-0.529; P < 0.001) and their parents were more likely to have a clinically significant stress score (OR 1.3, 95% CI 0.334-0.992; P = 0.047). Children with GDD were more likely to live in a disadvantaged suburb (OR 1.7, 95% CI 1.042-2.940; P = 0.034), more likely to have a sole parent (OR 1.8, 95% CI 1.062-3.082; P = 0.029) and much more likely to have had involvement with child protection services (OR 3.9, 95% CI 2.044-7.416; P < 0.001). CONCLUSIONS: Children with GDD without autism were more likely to be disadvantaged and to have had contact with child protection services than children with ASD. This has implications for the assessment, early intervention and support services for children with disabilities and their families.

Determinants of developmental progress in pre-schoolers referred for neuro-developmental diagnosis.

AIM: To determine factors associated with change in developmental progress in pre-schoolers referred to a developmental clinic. METHODS: Of 360 pre-schoolers referred to a Child Assessment clinic for neuro-developmental diagnosis before 3.6 years, 190 (53%) were reassessed prior to school entry and recruited to this study. They were assessed with the Bayley Scales of Infant and Toddler Development (3rd edn) before 3.5 years and the Griffiths Mental Development Scales before school entry. The influence of medical and environmental variables on improvement or deterioration in scores (±0.5 SD) was examined using logistic regression. RESULTS: Consistent scores were present in 51.6% of children, and associated with environmental variables. Children with stable scores were more likely to live in a suburb of social advantage (OR = 3.2; 95%CI = 1.37-7.64, P = 0.008) or to come from families dependent on welfare or public housing (OR=4.8; 95%CI = 2.19-10.49, P < 0.001). Improvement was seen in 18.1% of children; they were more likely to have commenced therapy after the first assessment (OR = 2.4; 95%CI = 1.05-5.58, P = 0.038). Deterioration of scores was seen in 30% of children. Children with a mild delay on initial assessment were less likely to deteriorate (OR = 2.9; 95%CI = 1.16-7.04, P = 0.022), while lower scores were more likely in children with neuro-motor disabilities (OR = 10.8; 95%CI = 2.64-44.58, P < 0.001), and chromosomal variations of both known and unknown significance (OR = 4.4; 95%CI = 1.54-12.76, P = 0.006). CONCLUSIONS: Socio-economic advantage and disadvantage are associated with stable scores, but introducing intervention is associated with improved scores. Deterioration is most likely in children with chromosomal variations or neuro-motor disabilities, and regular reassessment of these children is recommended.

Engagement of undergraduate medical students of paediatrics in special schools for children with disabilities.

AIMS: Over 200 000 Australian children suffer significant disability. How should medical students be prepared for this challenge? Community engagement has become fundamental to education, but there is little experience with engagement of undergraduates with children with disabilities. This paper reviews such experience in Western Sydney. METHODS: Since 2011, UWS paediatric students have been rotated through local special schools for 2 weeks each term. In 2013, feedback was solicited in a questionnaire from the 129 students involved that year with 109 being returned. It had been solicited from school staff and parents in formal and informal communication from the beginning. RESULTS: Fourteen per cent of students reported no prior exposure to disabled children: 55% only chance, 24% regular and 7% extensive. Thirty-seven per cent reported greatly increased understanding: 39% moderately, 15% somewhat, 7% a little and 2% not. Forty-three per cent declared understanding of impact on family greatly increased: 40% moderately, 11% somewhat, 5% a little and 1% not. Twenty-seven per cent declared greatly increased knowledge of services, 43% moderately, 25% somewhat, 4% a little and 1% none. Fifteen per cent declared greatly increased preparation for caring, 44% moderately, 30% somewhat, 6% a little and 5% none. Thirty-six per cent declared greatly increased understanding of role of schools, 30% moderately, 20% somewhat, 10% a little, and 2% none and 2% cannot recall. School staff and parents reported very favourably. Problems involved professionalism in students and some fatigue in parents. CONCLUSION: The engagement has been successful. Professionalism has been emphasised, and rotations have been designed to prevent fatigue.

Families referred to a Child Assessment Team: the Campbelltown experience.

AIM: To study the socio-demographic and psychosocial risk factors of families presenting with their children for a diagnostic developmental assessment. METHODS: Socio-demographic details of children who had a multidisciplinary developmental assessment with the Child Assessment Team at Campbelltown Hospital between January 2009 and December 2010 were collated and compared with census data. RESULTS: In 2009 and 2010, 277 families were seen by the Child Assessment Team. A detailed socio-demographic profile was available for 251 (91%) families. Parents seen in the clinic were more likely to be younger, single, born overseas, have less post-school education, identify as Aboriginal and/or live in public housing compared with the district rates. CONCLUSIONS: Families presenting to the developmental clinic have more socio-economic disadvantage compared with the referring district. This has implications for service delivery and clinical presentation, and highlights the importance of the social worker's role in a developmental diagnostic team.

The Gudaga Study: development in 3-year-old urban Aboriginal children.

AIM: The aim of this analysis was to study and explore factors associated with the developmental progress in urban Aboriginal children at 3 years. METHODS: The Gudaga Study is a longitudinal birth cohort study of urban Aboriginal infants. The children were assessed using the Griffiths Mental Development Scales, Extended Revised (GMDS-ER) and the Peabody Picture Vocabulary Test, Fourth Edition (PPVT-IV). Student's t-tests and multiple linear regression analysis were used to test the association between developmental progress and possible risk factors. RESULTS: Overall, the mean general quotient (GQ) for Gudaga children was significantly lower than the standardised norm (P < 0.001). In the GMDS-ER subscales, the scores were higher than expected in the locomotor (P = 0.002) and personal-social domains (P = 0.002) and lower than expected for language (P < 0.001), eye and hand coordination (P < 0.001), performance (P < 0.001) and practical reasoning (P < 0.001). Multiple regression analysis showed that maternal age (P = 0.02) and single-mother status (P = 0.04) were significantly associated with lower performance on the GMDS-ER. The GQ was inversely proportional to the number of risk factors present (P = 0.001). The mean score of the PPVT-IV was also lower than the PPVT-IV norms (P < 0.001). CONCLUSION: At 3 years, urban Aboriginal children show relative strengths in their locomotor and self-care skills and emerging delays in their language, fine motor and performance skills. Slower developmental progress was more likely in the context of young maternal age and single parenthood.

Appointment attendance at a remote rural dental training facility in Australia.

BACKGROUND: Non-attended appointments have impacts on the operations of dental clinics. These impacts vary from lost productivity, loss of income and loss of clinical teaching hours. METHODS: Appointment data were analysed to assess the percentage of completed, failed to attend (FTA) and cancelled appointments at an Australian remote rural student dental clinic training facility. The demographic and time characteristics of FTA and cancelled appointments were analysed using simple and multivariate multinomial regression analysis, to inform interventions that may be necessary. RESULTS: Over the 2-year study period a total of 3,042 appointments were made. The percentage of FTA was 21.3% (N = 648) and cancelled appointments 13.7% (N = 418). The odds of an FTA were in excess of 4 times higher in patients aged 19-25 years (OR = 4.1; 95% CI = 2.3-7.3) and 26-35 years (OR = 4.4; 95% CI = 2.5-7.9) compared to patients 65 years and older. The odds of an FTA was 2.3 (95% CI = 1.8-3.1) times higher in public patients compared to private patients. The odds of a cancellation was 1.7 (95% CI = 1.1-2.6) times higher on a Friday compared to a Monday and 1.8 (95% CI = 1.1-2.9) times higher on the last appointment of the day compared to the first appointment. For cancelled appointments, 71.3% were cancelled on the day of the appointment and 16.6% on the day before. CONCLUSIONS: Non-attended appointments (FTA or cancelled) were common at this remote rural dental clinic training facility. Efforts to reduce these need to be implemented; including telephonic reminders, educating the community on the importance of attending their appointments, block booking school children and double booking or arranging alternative activities for the students at times when non-attendance is common.

Adaptive function in preschoolers in relation to developmental delay and diagnosis of autism spectrum disorders: insights from a clinical sample.

This study aims to explore the relationship between developmental ability, autism and adaptive skills in preschoolers. Adaptive function was assessed in 152 preschoolers with autism, with and without developmental delay, and without autism, with and without developmental delay. Their overall adaptive function, measured by the general adaptive composite on the Adaptive Behaviour Assessment System, was closely correlated to developmental ability as measured by the general quotient on the Griffith Mental Development Scales. Children with autism performed significantly less well on both scales. Domain scores discriminated between children with and without autism, with poorer performance on both the social and practical domain scores for children with autism, even when controlling for the effects of development. Children with average development, both with and without autism, had lower adaptive skills than expected for their developmental level. The importance of considering domain scores as well as the general adaptive composite when determining support needs is emphasised.

Developmental and behavioural characteristics of children enrolled in a child protection pre-school.

AIM: The study aims to describe the developmental and behavioural difficulties in pre-school children who have experienced maltreatment and/or neglect METHODS: A retrospective medical file audit of all children assessed at the Cottage Family Care Centre, a child protection pre-school, between April 2004 and June 2010. Demographic characteristics, parent and teacher reports, and clinical and developmental assessment results were collated and analysed. RESULTS: The average age of the 55 children assessed was 36.3 months (ranging from 14 to 55.3 months). Fifty-five per cent were male and 65% were from disadvantaged families. A significant developmental delay in at least one domain and or a significant behavioural problem was identified in 91% of assessments. Overall (or global) delay was found in 38% and this was significantly more likely in girls (P = 0.03). Emotional and/or behavioural difficulties were reported in 85% of children. Internalising problem behaviours were more common than externalising problems. A diagnosis of an autism spectrum disorder was made in four children. In the six review assessments, regression was identified in three children. CONCLUSIONS: Children who have experienced maltreatment and/or neglect may present with developmental delays and behavioural problems. Language delays and internalising problems are characteristic. There are many features in common with primary developmental disorders. The presence of fearfulness and hypervigilance may provide a clue to diagnosis.