Enhancing the Graduate Medical Education Clinical Learning Environment Through Community of Practice Forums.

ABSTRACT: An optimal clinical learning environment (CLE) is associated with improved learning and patient care outcomes. Significant concerns exist about the state of the CLE in graduate medical education (GME). Research suggests GME programming falls short in interpersonal aspects of training that promote trainee engagement and psychological safety. Furthermore, published educational interventions in the CLE lack adequate theoretical backing to inform a rational approach to interventions in the CLE that could address these important problems.The authors apply the 2002 work of Etienne Wenger on communities of practice (COP) to address these GME CLE concerns. To distinguish this COP intervention from earlier theoretical work on COPs, the authors refer to this management concept as "COP forums." COP forums favorably influence the GME CLE through effects that complement experiential learning in patient care. COP forums support trainee psychological safety, mentorship from near peers, and opportunities to innovate-effects that can serve as a counterbalance to the time pressures, hierarchy, and compliance culture often experienced in the clinical environment. Deliverables of COP forums, including practice innovation and trainee self-efficacy, can favorably impact organization-wide performance and engagement.This article describes the historical position of COP forums in the evolution of COP theory and outlines the basic structure and function of COP forums. It contrasts COP forums to other COP-related concepts to explain their relevance to the GME CLE. Examples of innovative GME COP forums illustrate the structure and function of these interventions. Finally, the authors call for more research on the impact of COP forums on the GME CLE. To avoid confusion, such scholarship must account for the ongoing evolution of the larger COP framework and target specific dimensions of the theory most pertinent to the medical education research question at hand.

Application in Parallel to U.S. Residency Training Programs in Multiple Specialties: Trends and Differences by Applicant Educational Background, 2009-2021.

PURPOSE: The medical education community is pursuing reforms addressing unsustainable growth in the number of residency applications per applicant and application costs. Little research has examined the prevalence or contributions of parallel applications (application to residency in multiple specialties) to this growth. METHOD: A retrospective analysis of Electronic Residency Application Service® data provided by the Association of American Medical Colleges was conducted. The percentage of applicants applying to ≥1 specialty, mean number of specialties applied, number of submitted applications, and percentage of applicants to each specialty who were parallel applying were determined. MD, DO, and international (U.S. international medical graduate [IMG] and IMG) applicants were included. RESULTS: The sample contained 586,246 applicant records from 459,704 unique applicants. The percentage of applicants who parallel applied decreased from 41.3% to 35.4% between 2009 and 2021. DO applicants were the only group for whom the percentage parallel applying increased (30.6% vs. 32.1%). IMG (60.4% vs. 49.1%) or USIMG applicants (69.6% vs. 63.1%) were groups with the greatest percentage of applicants parallel applying each year (2009-2021). The mean number of specialties applied to when parallel applying also decreased from 2.96 in 2009 to 2.79 in 2021, overall. Between 2009 and 2021, mean number of applications increased for all applicant types amongst both single-specialty applicant and parallel-applying applicants. Among applicants who were single-specialty applying, mean number of applications grew from 38.6 in 2009 to 74.6 in 2021 and from 95.2 to 149.8 for parallel-applying applicants. CONCLUSIONS: All applicant groups experienced decreases in percentages parallel applying except for DO applicants. Parallel application appears to be common and slowly declining, and does not appear to significantly contribute to increasing numbers of applications per candidate. Efforts to control the growth of applications per applicant should continue to focus on applicants' numbers of applications submitted to each specialty.

The Chicagoland Free Clinics Consortium: A Model for Student-Run Free Clinic Collaboration.

BACKGROUND: While student-run free clinics (SRFCs) play an important role in care for underserved populations, few mechanisms exist to promote collaboration among regional SRFCs. AIMS: To address this gap, the Chicagoland Free Clinics Consortium (CFCC) was formed to (1) facilitate collaboration between Chicagoland SRFCs, (2) provide innovation grant funding, and (3) host an annual conference. SETTING AND PARTICIPANTS: In 2018, students from the Pritzker School of Medicine founded the CFCC and partnered with peers from area schools to implement programming. PROGRAM DESCRIPTION: Between 2018 and 2022, CFCC engaged 23 SRFCs representing all 6 Chicagoland schools, held 4 annual conferences, and distributed $15,423 in grants to 19 projects at 14 SRFC sites. PROGRAM EVALUATION: A total of 176 students from 5 schools attended the 4 conferences. In 2022, 82 unique participants were surveyed, and 66% (54/82) responded. Eighty percent (43/54) reported they were "more likely to collaborate with other Chicagoland free clinics." In 2022, all grant sites were surveyed and 84% (16/19) responded. Most (87%,14/16) agreed the grant "allowed them to implement a project that would not have otherwise been accomplished" and 21% (4/19) were inter-institutional collaborations. DISCUSSION: To our knowledge, CFCC is the first student-led organization to promote sustained collaboration across SRFCs in a metropolitan area.

Beyond Compliance: Growth as the Guiding Value in Undergraduate Medical Education.

Adhering to the paradigm of the natural sciences, much of undergraduate medical education (UME) in the United States remains committed to objectivity, compliance, and standardization in its approach to teaching, evaluation, student affairs, and accreditation practices. The authors argue that, while these simple and complicated problem solving (SCPS) approaches may be valid for some highly controlled environments of UME, they lack rigor in complex, real-world environments where optimal care and education is not standardized but is tailored to context and individual needs. This argument is supported by evidence that "systems" approaches, characterized by complex problem solving (CPS, differentiated from complicated problem solving), lead to better outcomes in patient care and student academic performance. Examples of interventions implemented at the University of Chicago Pritzker School of Medicine from 2011 to 2021 further illustrate this point. Interventions in student well-being that emphasize personal and professional growth have led to student satisfaction that is 20% higher than the national average on the Association of American Medical Colleges Graduation Questionnaire (GQ). Career advising interventions that augment the use of adaptive behaviors in place of rules and guidelines have yielded 30% fewer residency applications per student than the national average while simultaneously yielding residency "unmatched" rates that are one-third of the national average. Regarding diversity, equity, and inclusion, an emphasis on civil discourse around real-world problems has been associated with student attitudes toward diversity that are 40% more favorable than the national average on the GQ. In addition, there has been an increase in the number of matriculating students who are underrepresented in medicine to 35% of the incoming class. The article concludes with a review of philosophic barriers to incorporating the CPS paradigm into UME and of notable pedagogic differences between CPS and SCPS approaches.

Breaking the Silence: A Mental Health Initiative to Reduce Stigma Among Medical Students.

PROBLEM: Mental health conditions are common among medical students. While stigma contributes to low rates of help seeking, little programming exists to address stigma. APPROACH: In 2015, the authors developed a mental health initiative (MHI) to combat stigma at the Pritzker School of Medicine featuring 3 elements: (1) Mental Health Panel, an annual first-year event where faculty/peers share mental health stories; (2) Pritzker, I Screwed Up, an annual all-school event where faculty/peers share experiences with failure; and (3) Humans of Pritzker, a social media initiative featuring students' mental health posts. Postevent surveys and the 2021-2022 MHI survey assessed student satisfaction and impact on stigma and help-seeking behaviors. Student Counseling Services utilization rates for medical and nonmedical students were compared for academic years 2014-2015 vs 2018-2019 and 2020-2021 to account for the pandemic's impact on mental health care utilization. OUTCOMES: The MHI survey response rate was 61% (261/430). Respondents were distributed across class-years. Most were female (57%, 150/261). The majority agreed they could speak about mental health without judgment from peers (78%, 203/259) and faculty (57%, 149/260). Most (62%, 161/260) utilized mental health services during medical school. Of these, 41% (66/161) agreed that MHI programming contributed to their decision to seek care. On the 2021-2022 Mental Health Panel and Pritzker, I Screwed Up evaluations, almost all agreed that faculty/peers sharing experiences destigmatized mental illness (99%, 78/79) and making mistakes (96%, 152/159). Student Counseling Services utilization increased from 8% (32/389) for 2014-2015 to 19% (75/394) for 2018-2019 and 33% (136/406) for 2020-2021 for medical students, compared with 19% (2,248/12,138) to 21% (3,024/14,293) and 22% (3,285/15,004) for nonmedical students. NEXT STEPS: Faculty and peers sharing mental health stories may help reduce stigma and increase help seeking in medical students. Future work should explore the longitudinal impact of programming and disseminating similar initiatives at other institutions.

Impact of the Early Phase of the COVID-19 Pandemic on Medical Student Well-Being: a Multisite Survey.

BACKGROUND: The COVID-19 pandemic drastically impacted medical student experiences. Little is known about the impact of the pandemic on student well-being and protective factors for burnout. OBJECTIVE: Assess US medical student burnout, stress, and loneliness during the initial phase of the pandemic, compare results to pre-pandemic data, and identify risk factors for distress and protective factors to inform support interventions. DESIGN: Cross-sectional survey of medical students conducted between May and July 2020. PARTICIPANTS: 3826 students from 22 medical schools. MAIN MEASURES: Burnout (MBI-HSS), stress (PSS-10), loneliness (UCLA scale), and student experiences. Compared burnout and stress to pre-pandemic studies (2010-2020). KEY RESULTS: Of 12,389 students, 3826 responded (31%). Compared to pre-pandemic studies, burnout was lower (50% vs. 52%, P = 0.03) while mean stress was higher (18.9 vs. 16.0, P < 0.001). Half (1609/3247) reported high (≥ 6/9) loneliness scores. Significant differences were found in burnout and stress by class year (P = 0.002 and P < 0.001) and race (P = 0.004 and P < 0.001), with the highest levels in second- and third-year students and Black, Asian, or other racial minority students. Students experiencing financial strain or racism had higher burnout and stress (P < 0.001 for all). Respondents with COVID-19 diagnoses in themselves or family members had higher stress (P < 0.001). Nearly half (1756/3569) volunteered during the pandemic, with volunteers reporting lower burnout [48% (782/1639) vs. 52% (853/1656), P = 0.03]. CONCLUSIONS: While stress was higher compared to pre-pandemic data, burnout was significantly lower. Higher burnout and stress among Black, Asian, and other racial minority students and those who experienced financial strain, racism, or COVID-19 diagnoses likely reflect underlying racial and socioeconomic inequalities exacerbated by the pandemic and concurrent national racial injustice events. Volunteer engagement may be protective against burnout. Schools should proactively support vulnerable students during periods of stress.

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs.

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient-clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers' work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

National Survey of Wellness Programs in U.S. and Canadian Medical Schools.

PURPOSE: To describe the prevalence and scope of wellness programs at U.S. and Canadian medical schools. METHOD: In July 2019, the authors surveyed 159 U.S. and Canadian medical schools regarding the prevalence, structure, and scope of their wellness programs. They inquired about the scope of programming, mental health initiatives, and evaluation strategies. RESULTS: Of the 159 schools, 104 responded (65%). Ninety schools (93%, 90/97) had a formal wellness program, and across 75 schools, the mean full-time equivalent (FTE) support for leadership was 0.77 (standard deviation [SD] 0.76). The wellness budget did not correlate with school type or size (respectively, P = .24 and P = .88). Most schools reported adequate preventative programming (62%, 53/85), reactive programming (86%, 73/85), and cultural programming (52%, 44/85), but most reported too little focus on structural programming (56%, 48/85). The most commonly reported barrier was lack of financial support (52%, 45/86), followed by lack of administrative support (35%, 30/86). Most schools (65%, 55/84) reported in-house mental health professionals with dedicated time to see medical students; across 43 schools, overall mean FTE for mental health professions was 1.62 (SD 1.41) and mean FTE per student enrolled was 0.0024 (SD 0.0019). Most schools (62%, 52/84) evaluated their wellness programs; they used the Association of American Medical Colleges Graduation Questionnaire (83%, 43/52) and/or annual student surveys (62%, 32/52). The most commonly reported barrier to evaluation was lack of time (54%, 45/84), followed by lack of administrative support (43%, 36/84). CONCLUSIONS: Wellness programs are widely established at U.S. and Canadian medical schools, and most focus on preventative and reactive programming, as opposed to structural programming. Rigorous evaluation of the effectiveness of programs on student well-being is needed to inform resource allocation and program development. Schools should ensure adequate financial and administrative support to promote students' well-being and success.

Supporting Inclusive Learning Environments and Professional Development in Medical Education Through an Identity and Inclusion Initiative.

In 2015, the Pritzker School of Medicine experienced increasing student interest in the changing sociopolitical landscape of the United States and the interaction of these events with student and patient identity. To address this interest, an Identity and Inclusion Steering Committee was formed and formally charged with "providing ongoing direction for programs and/or curricula at Pritzker that support an inclusive learning environment and promote respectful and effective communication with diverse patients and colleagues around issues of identity." The authors describe this committee's structure and steps taken by the committee to create an inclusive community of students at Pritzker characterized by learning through civil discourse. Initiatives were guided by a strategy of continuous quality improvement consisting of regular iterative evaluation, ongoing school-wide engagement, and responsiveness to issues and concerns as they emerged. Data collected over the committee's 4-year existence demonstrate significant improvement in students' sense of inclusion and respect for different perspectives on issues related to identity, such as access to health care, racialized medicine, safe spaces, and nursing labor strikes. The authors discuss several principles that support the development of an inclusive community of students as well as challenges to the implementation of such programming. They conclude that a strategy of continuous quality improvement guided by values of social justice, tolerance, and civil discourse can build community inclusion and enhance medical training for the care of diverse patient populations.

Accounting for complexity in medical education: a model of adaptive behaviour in medicine.

CONTEXT: Medicine is practised in complex systems. Physicians engage in clinical and operational problems that are dynamic and lack full transparency. As a consequence, the behaviour of medical systems and diseases is often unpredictable. Medical science has equipped physicians with powerful tools to favourably impact health, but a reductionist approach alone is insufficient to optimally address the complex challenges posed by illness and public health. Concepts from complexity science, such as continuous quality improvement and teamwork, strive to fill the gap between biomedical knowledge and the realities of practice. However, the superficial treatment of these systems-thinking concepts in medical education has distorted their implementation and undermined their impact. 'Systems thinking' has been conflated with 'systematic thinking'; concepts which are adaptive in nature are being taught as standardised, reductionist tools. METHODS: Using concepts from complexity science, the history of science and psychology, this problem is outlined and a theoretical model of professional development is proposed. RESULTS: This model proposes that complex problem solving and adaptive behaviour, not technical expertise, are distinguishing features of professionalism. DISCUSSION: The impact of this model on our understanding of physician autonomy, professionalism, teamwork and continuous quality improvement is discussed. This model has significant implications for the structure and content of medical education. Strategies for enhancing medical training, including interventions in recruitment, the curriculum and evaluation, are reviewed. Such adjustments would prepare trainees to more effectively utilise biomedical knowledge and tools in the complex high-stakes reality of medical practice.

Medical student resilience and stressful clinical events during clinical training.

BACKGROUND: Medical students face numerous stressors during their clinical years, including difficult clinical events. Fostering resilience is a promising way to mitigate negative effects of stressors, prevent burnout, and help students thrive after difficult experiences. However, little is known about medical student resilience. OBJECTIVE: To characterize medical student resilience and responses to difficult clinical events during clinical training. DESIGN: Sixty-two third-year (MS3) and 55 fourth-year (MS4) University of Chicago medical students completed surveys in 2016 assessing resilience (Connor Davidson Resilience Scale, CD-RISC 10), symptoms of burnout, need for resilience training, and responses to difficult clinical events. RESULTS: Medical student mean resilience was lower than in a general population sample. Resilience was higher in males, MS4s, those without burnout symptoms, and students who felt able to cope with difficult clinical events. When students experienced difficult events in the clinical setting, the majority identified poor team dynamics among the most stressful, and agreed their wellbeing was affected by difficult clinical events. A majority also would prefer to discuss these events with their team later that day. Students discussed events with peers more than with attendings or residents. Students comfortable discussing stress and burnout with peers had higher resilience. Most students believed resilience training would be helpful and most beneficial during MS3 year. CONCLUSIONS: Clinical medical student resilience was lower than in the general population but higher in MS4s and students reporting no burnout. Students had some insight into their resilience and most thought resilience training would be helpful. Students discussed difficult clinical events most often with peers. More curricula promoting medical student resilience are needed.