Preceptors' preparedness to teach about substance and opioid use disorder: a qualitative study.

STUDY AIM: Little is known about preceptors' comfort and readiness to teach clinical students about the care of patients with substance and opioid use disorder (SUD/OUD). This study explores preceptors' views about caring for such patients, and their preparedness to teach about SUD/OUD management, to improve graduate competencies. METHODS: Participants were recruited by convenience and snowball sampling. Semi-structured interviews were conducted with physician, physician assistant, and nurse practitioner preceptors who taught medical and physician assistant students. Interviews were conducted via Zoom® videoconferencing. Transcripts were generated and independently analyzed for themes by 4 experienced coders using constant comparison and a grounded theory approach. RESULTS: Fifteen interviews were conducted to theme saturation. We identified 3 major themes and 10 subthemes supported by exemplar quotes. The major themes were: education about SUD/OUD in primary care (subthemes include need for longitudinal curriculum, redefining 'success' in treatment, and precepting challenges), treatment of SUD/OUD in primary care (need for systemic support and care continuity), and medication-assisted therapy (MAT) training as a tool for teaching (preceptors' own training, and need for clinical students to be trained). CONCLUSIONS: Preceptors agreed that treatment of SUD/OUD belongs in primary care and students should learn about SUD/OUD from the start of their medical education. Data analysis enabled the construction of an emerging conceptual framework reflecting a diversity of experiences and opinions of preceptor comfort and preparedness to teach about SUD/OUD, associated with various barriers and motivators. This framework can guide future strategies to address facilitators and obstacles to advance and promote preceptor preparedness to teach students about the care and management of patients with SUD/OUD.

Inclusion of the homeless in health equity curricula: a needs assessment study.

Exposure to homeless patients is a potential strategy to teach about social determinants of health and health inequities. Little is known about student attitudes and preferences for learning about the homeless in curricula addressing vulnerable populations. A needs assessment to determine student readiness may inform strategies for teaching. A mixed-methods study of one matriculating physician assistant student class, with a cross-sectional survey and 3 focus groups (FG). The validated 19-item Health Professionals' Attitudes Toward Homelessness inventory (HPATHI) and new 7-item Learning Attitudes scale were administered to explore perceptions and preferences about relevance of caring for the homeless to future practice. FGs were conducted to theme saturation. Verbatim transcripts were independently read and coded by 3 researchers using constant comparison. Survey response rate was 100% (N = 60). Overall HPATHI mean score was 3.97 ± 0.04 of 5, indicating positive attitudes toward the homeless. The highest mean score (4.26 ± 0.04) was for the social advocacy subscale; the lowest (3.02 ± 0.06) for personal advocacy. The Learning Attitude scale (Cronbach's alpha 0.89) mean score was 4.47 ± 0.07 out of 5, showing a positive attitude toward curricular exposure. Older students and those with prior experience with the homeless had higher HPATHI scores (p < 0.05). Four major themes emerged: vulnerable patients cannot advocate for themselves; learning about homelessness is relevant to future practice; preference for multiple teaching strategies and adequate preparation for street rotations; and anticipated anxiety about safety. Students recognize the value of learning from homeless patients as part of gaining skills in caring for vulnerable populations. Experiential learning opportunities focusing on this group are seen as an acceptable and valuable way to gain skills applicable to all vulnerable patients. Students express fear and anxiety around non-traditional settings such as the street. Their anxieties should be adequately addressed when designing clinical rotations.

Impact of a Longitudinal Medical Spanish Curriculum on Student Communication Skills.

PURPOSE: This study describes and examines the short- and longer-term impact of a required longitudinal medical Spanish curriculum on physician assistant student preparedness and ability to communicate with patients in Spanish during clinical rotations. METHODS: Fifty-eight preclinical students participated in an 80-hour curriculum delivered weekly over 3 semesters. Teaching followed a framework of second-language acquisition and included structured grammar and medical vocabulary practice with didactic, interactive, and group assignments. Vocabulary and grammar were assessed with quizzes. Oral proficiency was assessed by faculty with Spanish Objective Structured Clinical Examination (OSCE) stations at midpoint and end using the Interagency Language Roundtable (ILR), a 6-level scale (immediate outcome). Students self-rated proficiency and confidence and evaluated curriculum effectiveness for preparing them to care for Spanish-speaking patients (longer-term outcomes). RESULTS: All students passed the written and oral quizzes. Faculty-scored ILR verbal proficiency at the OSCEs increased by a mean level of 0.5 over 6 months. Student self-assessed proficiency improved on average by one level from baseline to 24 months later. Students rated highly curriculum effectiveness, preparedness to communicate in Spanish during clinical rotations, ability to judge when an interpreter was needed, and the importance of medical Spanish to future practice. CONCLUSIONS: A required integrated longitudinal medical Spanish curriculum was well received. Physician assistant students demonstrated short-term interval progression in Spanish proficiency, with improvements in both faculty and self-rating scores, and readiness to apply the skill to practice. They valued active learning associated with repeated practice with feedback, role playing, and interval assessments throughout the curriculum.

Video Technology to BOOST Preceptor Recruitment: A Mixed Methods Study.

PURPOSE: This study's aim was to examine the impact of a brief video presentation for changing clinician knowledge and attitude about precepting physician assistant (PA) students. METHODS: In this mixed methods study, we developed a 12-minute video and made presentations to potential preceptors. Change in knowledge and attitudes was assessed with a pre/post survey. We conducted focus groups (FGs) to elicit barriers and motivators for precepting PA students and assessed acceptability and impact of the video. RESULTS: Twenty-three preceptors participated in three 45-minute presentations. Participants showed significant knowledge increase in 7 of 10 survey questions. After the presentation, willingness to precept PA students was high. Major FG themes were: teaching is motivating, need clarity about PA students' needs, need support to teach, prefer video presentation to email, and similarities with medical student teaching is positive. CONCLUSIONS: A brief in-person video presentation is acceptable and is associated with increased knowledge and comfort in precepting PA students.

Evaluating Medical Spanish Proficiency: A Comparison of Physician Assistant Student Self-Assessment to Standardized Patient and Expert Faculty Member Ratings.

PURPOSE: Whether physician assistant (PA) students' self-assessment or standardized patient (SP) evaluations of students' medical Spanish proficiency accurately reflect their language proficiency is unclear. This study compares PA student and SP ratings with an expert faculty member's rating to determine whether student or SP ratings can be used to evaluate language proficiency. METHODS: Fifty-eight students participated in a single-station Spanish Objective Structured Clinical Examination (OSCE) at the midpoint of a medical Spanish curriculum. Using the Interagency Language Roundtable (ILR)-a 6-point, single-item language proficiency scale previously validated among physicians-PA students and SPs evaluated students' medical Spanish proficiency. Their scores were then compared with the scores derived by an expert faculty rater who had viewed a video of each student-SP encounter. The faculty's score was considered the gold standard. Correlation between scores was calculated using Spearman's rank correlation coefficient. RESULTS: Mean student scores were highest when rated by SPs (M = 3.8, SD = 0.9), followed by self (M = 3.0, SD = 0.9), and then faculty (M = 2.5, SD = 1.2). Spearman's rank correlation coefficient showed a strong positive correlation between students and the expert faculty rater (rs = 0.67, P < .001) and between SPs and the expert faculty rater (rs = 0.72, P < .001). The correlation was stronger for high- than for low-proficiency students. Students' self-rated scores showed significant improvement from baseline to the OSCE. CONCLUSIONS: PA students participating in a medical Spanish curriculum and SPs show good correlation with an expert faculty rater in assessing Spanish proficiency during an OSCE. Standardized patients demonstrate scoring leniency. The ILR has potential for tracking aggregate student progress and curriculum effectiveness. With training, student self-rating could be used for interval assessment of medical Spanish communication.

Impact of a Required Service-Learning Curriculum on Preclinical Students.

PURPOSE: The impact of brief service-learning curricula on physician assistant (PA) students is not well reported. This study explores student learning immediately and then one to 2 years after a preclinical service-learning experience through written reflections and a survey. METHODS: The 16-hour curriculum within a behavioral science course involved community immersion and engagement with underserved clients. Reflections written by students from 3 consecutive classes were coded for major themes, and theme frequency was assessed. We then administered a survey to explore the curricular impact after students completed their clinical clerkships. RESULTS: All students (132/132) completed the required curriculum. We identified 4 major themes from 132 reflections. The themes were (most to least frequent) self-discovery (54/132), patient focus (30/132), community resources (28/132), and patient-provider relationship (20/132). The primary attitude change (self-discovery) was student awareness of their own biases and recognition of the need for cultural humility when caring for underserved clients. In the postcurriculum survey (response 69/95), students recalled community resources as the most important learning, followed by self-discovery. Students viewed the curriculum positively and noted that the exposure increased their comfort with caring for underserved patients in their clerkships. CONCLUSIONS: Immersion in a community-based service-learning experience with underserved clients is associated with increased self-awareness and intent to change behavior. Students perceive the experience as important for future clerkships. Preclinical service-learning curricula prepare students to care for underserved patients.

Psychological Comfort of Paramedics with Field Death Pronouncement: A National Asian Study to Prepare Paramedics for Field Termination of Resuscitation.

OBJECTIVES: Paramedics' decision to terminate field resuscitation without a physician present may depend on personal and external factors. This study investigates factors associated with paramedic psychological comfort with termination of resuscitation (TOR) to inform future training. METHODS: We administered an anonymous survey to all practicing paramedics in a large urban Asian Emergency Medical Services system where formal TOR training had not yet been conducted and field TOR was not routinely applied. The survey assessed psychological comfort using the validated Psychological Comfort Total (PCT) scale (summed score of 28 items, with higher scores representing greater comfort). We examined scores associated with four personal (prior resolution of personal loss, knowledge of survival probability, religious affiliation and experience with death pronouncements) and two external (location of patient and perceived trust of family) factors. Data were entered into Excel and analyzed by t-tests and ANOVA. RESULTS: Response rate was 73.6% (254/345). Respondents were 30.3 years (mean, SD 7.1) with 7.2 years (mean, SD 5.54) of practice experience. Over 60% had been involved in 6 or more field death pronouncements in the prior 12 months. Higher PCT scores were associated with prior resolution of personal loss and knowledge of survival probability. Lower PCT scores were associated with patient location in a public place and perceived family lack of trust. PCT scores were not associated with paramedic religious affiliation or number of prior death pronouncements. CONCLUSIONS: Paramedic psychological comfort with field death pronouncement is associated with personal and external factors. Since paramedic comfort is important for protocol adoption, TOR education should target not only knowledge, but also public arena management, communication skills for engaging with families, and help paramedics resolve prior personal loss.

Using a personality inventory to identify risk of distress and burnout among early stage medical students.

BACKGROUND: Distress and burnout are common among medical students and negatively impact students' physical, mental, and emotional health. Personality inventories such as the Myers-Briggs Type Indicator (MBTI), used in medical education, may have a role in identifying burnout risk early. METHODS: The authors conducted a cross-sectional survey study among 185 1st year medical students with the MBTI, the general well-being schedule (GWB), and Maslach Burnout Inventory-Student Survey (MBI-SS). Descriptive statistics and one-way MANOVAs were used to identify the prevalence and differences in MBTI preferences and distress/burnout risk. RESULTS: Response rate was 185/185 (100%). Distress (GWB) was reported by 84/185 (45.4%). High scores on exhaustion were reported by 118/182 (64.8%), cynicism by 76/182 (41.8%), and decreased professional efficacy by 38/182 (20.9%) for the three dimensions of the MBI-SS. Only 21/182 (11.5%) of respondents had high scores on all three dimensions of burnout. Students with MBTI preferences for extraversion reported greater positive well-being (P < 0.05), self-control (P < 0.05), professional efficacy (P < 0.01), and lower levels of depression (P < 0.01) compared with those with introversion preference. DISCUSSION: Distress and burnout are prevalent early in medical training. The significant difference between extraversion and introversion in relation to distress and burnout deserves further study. Use of a personality inventory may help identify students at risk of burnout and allow appropriate early stress management.

When less is more: validating a brief scale to rate interprofessional team competencies.

BACKGROUND: There is a need for validated and easy-to-apply behavior-based tools for assessing interprofessional team competencies in clinical settings. The seven-item observer-based Modified McMaster-Ottawa scale was developed for the Team Objective Structured Clinical Encounter (TOSCE) to assess individual and team performance in interprofessional patient encounters. OBJECTIVE: We aimed to improve scale usability for clinical settings by reducing item numbers while maintaining generalizability; and to explore the minimum number of observed cases required to achieve modest generalizability for giving feedback. DESIGN: We administered a two-station TOSCE in April 2016 to 63 students split into 16 newly-formed teams, each consisting of four professions. The stations were of similar difficulty. We trained sixteen faculty to rate two teams each. We examined individual and team performance scores using generalizability (G) theory and principal component analysis (PCA). RESULTS: The seven-item scale shows modest generalizability (.75) with individual scores. PCA revealed multicollinearity and singularity among scale items and we identified three potential items for removal. Reducing items for individual scores from seven to four (measuring Collaboration, Roles, Patient/Family-centeredness, and Conflict Management) changed scale generalizability from .75 to .73. Performance assessment with two cases is associated with reasonable generalizability (.73). Students in newly-formed interprofessional teams show a learning curve after one patient encounter. Team scores from a two-station TOSCE demonstrate low generalizability whether the scale consisted of four (.53) or seven items (.55). CONCLUSION: The four-item Modified McMaster-Ottawa scale for assessing individual performance in interprofessional teams retains the generalizability and validity of the seven-item scale. Observation of students in teams interacting with two different patients provides reasonably reliable ratings for giving feedback. The four-item scale has potential for assessing individual student skills and the impact of IPE curricula in clinical practice settings. ABBREVIATIONS: IPE: Interprofessional education; SP: Standardized patient; TOSCE: Team objective structured clinical encounter.

Is there a role for the use of aviation assessment instruments in surgical training preparation? A feasibility study.

BACKGROUND: Selection for surgical residency programmes could potentially be improved through pretraining preparation, after assessment of surgical candidates' sensorimotor skills and personality traits. Existing aviation pilot selection instruments are available to test sensorimotor skills and personality traits. This study examined selected instruments to assess medical trainees' sensorimotor skills and personality traits. METHODS: Aviation's validated computer-based Computerized Pilot Aptitude and Screening System (COMPASS) and Checklist Professional Profile (CPP) were applied to 166 final year medical students during a surgical clerkship between 2013 and 2015. RESULTS: All trainees completed COMPASS and CPP within the prescribed 2 hours. Compared with an age-matched and gender-matched cohort of 165 pilot candidates, medical trainees scored significantly higher on eye-hand coordination (p<0.001), need for variation (p<0.001), empathy (p=0.006), helpfulness (p<0.001) and autonomy (p<0.001). Pilot candidates scored higher on eye-hand-foot coordination (p<0.001), spatial orientation (p<0.001), persuasiveness (p<0.001), stress tolerance (p<0.001), dominance (p<0.001), ambition (p<0.001) and resilience (p<0.001). CONCLUSIONS: Final year medical trainees from one medical school were able to complete aviation's sensorimotor skills and personality traits selection instruments within the set time frame. They scored differently from aviation trainees on selected skills and personality traits. The applicability and utility of aviation instruments to presurgical training preparation remains to be tested.

What and how do students learn in an interprofessional student-run clinic? An educational framework for team-based care.

BACKGROUND: The student-run clinic (SRC) has the potential to address interprofessional learning among health professions students. PURPOSE: To derive a framework for understanding student learning during team-based care provided in an interprofessional SRC serving underserved patients. METHODS: The authors recruited students for a focus group study by purposive sampling and snowballing. They constructed two sets of semi-structured questions for uniprofessional and multiprofessional groups. Sessions were audiotaped, and transcripts were independently coded and adjudicated. Major themes about learning content and processes were extracted. Grounded theory was followed after data synthesis and interpretation to establish a framework for interprofessional learning. RESULTS: Thirty-six students from four professions (medicine, physician assistant, occupational therapy, and pharmacy) participated in eight uniprofessional groups; 14 students participated in three multiprofessional groups (N = 50). Theme saturation was achieved. Six common themes about learning content from uniprofessional groups were role recognition, team-based care appreciation, patient experience, advocacy-/systems-based models, personal skills, and career choices. Occupational therapy students expressed self-advocacy, and medical students expressed humility and self-discovery. Synthesis of themes from all groups suggests a learning continuum that begins with the team huddle and continues with shared patient care and social interactions. Opportunity to observe and interact with other professions in action is key to the learning process. DISCUSSION: Interprofessional SRC participation promotes learning 'with, from, and about' each other. Participation challenges misconceptions and sensitizes students to patient experiences, health systems, advocacy, and social responsibility. Learning involves interprofessional interactions in the patient encounter, reinforced by formal and informal communications. Participation is associated with interest in serving the underserved and in primary care careers. The authors proposed a framework for interprofessional learning with implications for optimal learning environments to promote team-based care. Future research is suggested to identify core faculty functions and best settings to advance and enhance student preparation for future collaborative team practice.

Interprofessional education and practice guide No. 5: Interprofessional teaching for prequalification students in clinical settings.

The importance of interprofessional education in health professions training is increasingly recognised through new accreditation guidelines. Clinician teachers from different professions may find themselves being asked to teach or supervise learners from multiple health professions, focusing on interprofessional dynamics, interprofessional communication, role understanding, and the values and ethics of collaboration. Clinician teachers often feel prepared to teach learners from their own profession but may feel ill prepared to teach learners from other professions. In this guide, we draw upon the collective experience from two countries: an institution from the United States with experience in guiding faculty to teach in a student-run interprofessional clinic and an institution from Canada that offers interprofessional experiences to students in community and hospital settings. This guide offers teaching advice to clinician educators in all health professions who plan to or already teach in an interprofessional clinical setting. We anticipate that clinician teachers can learn to fully engage learners from different professions, precept effectively, recognise common pitfalls, increase their confidence, reflect, and become role models to deliver effective teaching in interprofessional settings.

Evaluating Interprofessional Team Performance: A Faculty Rater Tool.

INTRODUCTION: Reliable team assessment has become a priority because of growing emphasis on interprofessional education and team-based care. Objective rating scales are needed to evaluate interprofessional student teams and individuals and provide real-time feedback. METHODS: In response to a need for behavioral rating scales, we modified the McMaster-Ottawa Scale from a 9-point to a 3-point scale and added descriptive behavioral anchors to define three levels of competency (i.e., below, at, and above expected). This modification is intended to provide consistent rating of individuals and teams in patient settings. We then developed a demonstration video using actors representing four professions to demonstrate the three levels of performance within the team. Our faculty rater tool, consisting of the modified scale and video, is designed to provide standardized ratings in interprofessional educational settings that involve patient care. RESULTS: We conducted training sessions with 40 faculty members from seven professions (medicine, dentistry, occupational therapy, nursing, pharmacy, physician assistant, and psychology) over a 2-year period. Immediately after each training session, two trained faculty observers rated interprofessional student teams as they conducted history and assessments on standardized patients. Observer scores were compared with one another and with standard expert ratings of the same teams. Trained observer ratings were consistent across the pairs. The observer training can be conducted within 60-90 minutes with the tool. DISCUSSION: Results of our implementation of the faculty rater tool confirm that the modified McMaster-Ottawa Scale is feasible to administer in clinical settings and that the demonstration video can be easily adopted for standardizing observer ratings.

What do medical students learn when they follow patients from hospital to community? A longitudinal qualitative study.

CONTEXT: Although longitudinal community-based care of patients provides opportunities for teaching patient centredness and chronic disease management, there is a paucity of literature assessing learning outcomes of these clerkships. This study examines learning outcomes among students participating in longitudinal community based follow-up of patients discharged from the hospital. METHODS: The authors conducted a thematic analysis of 253 student narratives written by 44 third-year medical students reflecting on their longitudinal interactions with patients with chronic medical illnesses. The narratives were written over three periods: after acute hospital encounter, after a home visit and at the end of the 10-month follow-up. Analysis involved coding of theme content and counting of aggregate themes. RESULTS: The most frequent theme was 'chronic disease management' (25%) followed by 'patient-centred care' (22%), 'health care systems' (20.9%), 'biomedical issues' (19.7%), 'community services' (9.5%) and 'student's role conflict' (2.3%). There was a shift in the relative frequency of the different themes, as students moved from hospital to community with their patients. Biomedical (44.3%) and health systems (18.2%) were the dominant themes following the acute hospitalization encounter. Chronic disease management (35.1%) and patient centredness (31.8%) were the dominant themes after the 10-month longitudinal follow-up. CONCLUSION: Longitudinal community-based interaction with patients resulted in learning about chronic disease management, patient centredness and health care systems over time. Students shifted from learning biomedical knowledge during the acute hospitalization, to focus on better understanding of long-term care and patient centredness, at the end of the module.

Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research.

BACKGROUND: Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities. OBJECTIVE: The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research. DESIGN: The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included. MEASUREMENTS: Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted. RESULTS: Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect. CONCLUSION: There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Interpreting values conflicts experienced by obstetrics-gynecology clerkship students using reflective writing.

PURPOSE: To examine students' responses to reflective practice assignments used in medical ethics and professionalism education. The study goals include an examination of what reflective writing reveals about students' personal and professional values, identification of the narrative typologies students use to tell stories of ethical dilemmas, and a determination of the usefulness of reflective writing in informing ethics/professionalism curricula assessment and development. METHOD: This study employed a mixed-methods design generating both descriptive data and interpretive analysis. Students' reflective writing assignments, guided by a series of six questions designed to elicit students' perceptions of moral conflicts they have encountered and their personal and professional ethical values, were collected from three successive cohorts of third-year medical students (n = 299) from July 2002 to January 2006 during an obstetrics-gynecology clerkship at the University of California, Irvine, School of Medicine. Content, thematic, and global narrative analyses of students' reflective writing were conducted, drawing on content analysis, grounded theory, and narrative methodologies. RESULTS: Values conflicts usually were patient centered (181; 60.5%) and student centered (172; 57.5%), without much regard for important contextual issues such as patients' socioeconomic status, insurance coverage, or culture. Common personal values included religious beliefs (82; 27.4%), respect (72; 24.1%), and the Golden Rule (66; 22.1%); frequent professional values were respect (72; 25.1%), beneficence (71; 23.7%), nonmaleficence (69; 23.1%), and autonomy (65; 21.7%). Whereas 35.5% (106) claimed to have addressed conflicts, 23.4% (70) said they did nothing. Restitution narratives (113; 37.8%) dominated. CONCLUSIONS: This analytic approach facilitated assessment of student values, conflict sources, and narrative types. Findings reveal aspects of the influence of the hidden curriculum and can inform strategies for effective implementation of bioethics/professionalism curricula.