Under- and post-graduate training to manage the acutely unwell patient: a scoping review.

BACKGROUND: Junior doctors are often the first responders to acutely unwell patients and yet frequently report feeling under-prepared to do so. To understand whether this is consequential of how medical students and doctors are trained to manage acutely unwell patients, a scoping review was conducted using a systematic approach. METHODS: The review, informed by the Arksey and O'Malley and PRISMA-ScR guidelines, identified educational interventions targeting the management of acutely unwell adults. Seven major literature databases were searched for journal articles published in English from 2005 to 2022, in addition to the Association of Medical Education in Europe (AMEE) conference proceedings from 2014 to 2022. RESULTS: Seventy-three articles and abstracts were eligible for the review, the majority of which were from the UK or USA, and demonstrated that educational interventions were more commonly targeted at medical students than qualified doctors. The majority of studies used simulation, but very few integrated complexities of the clinical environment within scenarios such as multidisciplinary working, distraction-handling techniques and other non-technical skills. A wide range of learning objectives pertaining to acute patient management were stated across studies, but few explicitly cited educational theory underpinning their study. CONCLUSIONS: The results of this review encourages future educational initiatives to consider enhancing authenticity within simulation to promote transfer of learning to clinical practice, and use educational theory to augment the sharing of educational approaches within the community of clinical education practice. Additionally, increasing the focus on post-graduate learning, building upon undergraduate educational foundations, is essential to promoting lifelong learning within the ever-changing healthcare environment.

Using Insights From Sports Psychology to Improve Recently Qualified Doctors' Self-Efficacy While Managing Acutely Unwell Patients.

PROBLEM: Doctors experience a range of negative reactions when managing acutely unwell patients. These may manifest as emotions or behaviors. Without appropriate coping strategies, these emotions and behaviors can impede optimal clinical performance, which directly affects patient care. Athletes use performance enhancing routines (PERs) to minimize the effect of their negative emotions and behaviors on competitive performance. The authors investigated whether PERs could similarly improve recently qualified doctors' emotional and behavioral control while managing acutely unwell patients and whether the doctors perceived any effect on clinical performance. APPROACH: Twelve doctors within 2 years of graduation from medical school recruited from 2 sites in Sheffield and Chesterfield, United Kingdom, implemented PERs using the PERFORM (Performance Enhancing Routines For Optimization of Readiness using Metacognition) model over a 4-month period between April and December 2017. The doctors' perceptions of PERFORM's effect on their ability to manage patients was evaluated using self-reported mixed-methods data, including think-aloud commentaries, semistructured interviews, and self-efficacy scores. OUTCOMES: Doctors reported that PERFORM improved their ability to control negative emotions or behaviors during an acutely unwell patient in situ simulation, showing a statistically significant improvement in self-efficacy scores (P = .003, effect size = 0.89). Qualitative data revealed perceived improvement in aspects of clinical performance such as enhanced knowledge recall and decision making. These performance attributes appeared to positively impact interprofessional relationships and patient care. Doctors individualized their PERs and supported the wider implementation of PERFORM in health care education. NEXT STEPS: This is the first study to employ individualized PERs based on sports psychology in a medical context. The PERFORM model could be introduced into existing acute patient management courses to provide emotional regulation coaching alongside clinical skills training. Further research might investigate PERFORM's effect in other environments where emotional and behavioral control is paramount, such as surgery.

Twelve tips for facilitating medical students prescribing learning on clinical placement.

Prescribing is a complex clinical skill requiring mastery by the end of basic medical training. Prescribing errors are common in newly qualified doctors, aligned with expressed anxiety about prescribing, particularly with high-risk medications. Learning about prescribing needs to start early in medical training, underpinned by regular opportunities for reflective practice. Authentic learning within the clinical work environment is more effective than lecture based learning and allows potential immediate feedback. Educational strategies should support prescribing learning underpinned by appropriate formative and summative assessments. Students should routinely be expected to use resources including an online formulary, sustained through tracking individual progress through use of their own personal formulary or 'p' drugs. Regular prescribing practice with embedded feedback during undergraduate training will help to ensure newly qualified doctors are more confident and competent prescribers.

Pre-University education curriculum reform and the generic learning skills of medical school entrants: Lessons learned from South Africa.

Background: Pre-university education curriculum changes may increase the skills and knowledge gap between secondary (high school) and tertiary (university) education that have been identified as having a major impact on the success of students from underresourced educational backgrounds. This study investigated the impact of extensive pre-university curriculum revision on the generic learning skills of entrants to South African medical schools, which admit students directly from high school. Methods: In this prospective study, students entering four medical schools during 2008-2011 were surveyed to determine their practice of and confidence in information handling, managing own learning, technical and numeracy skills, and computer, organizational, and presentation skills in the 12-month preceding entry. The 2008 entrants were the final cohort of the old secondary school curriculum. The mean levels of practice or confidence of entrants to the four medical schools, during 2008-2011, were compared using analysis of variance. The Bonferroni's test was used for further pair-wise comparison of cohorts of students either entering in different years or different institutions. Results: While entrants at the four medical schools did not demonstrate a consistent or sustained change in their practice of or confidence in each skill category over the period of study, there were some significant differences between entrants at the respective institutions. Furthermore, entrants to one medical school were consistently less confident of their skills, despite more practice. These findings are best accounted for by the long-standing history of inequitably resourced pre-university education in South Africa. Discussion: These findings highlight the need for close monitoring of the impact of pre-university education changes on the learning skill profiles of university entrants, in order to design effective university programs which enable students from diverse backgrounds to participate and adequately meet curricula demands.

What can medical educators learn from the Rio 2016 Olympic Games?

Medical Educators face an ongoing challenge in optimizing preparedness for practice for newly qualified doctors. Junior doctors have highlighted specific areas in which they do not feel adequately equipped to undertake their duties, including managing the acutely unwell patient. In these highly stressful, time-critical scenarios it might be assumed that a lack of knowledge underpins these feelings of apprehension from junior medics; however, having studied, trained and passed examinations to demonstrate such knowledge, perhaps other factors should be considered. The recent Olympic Games in Rio demonstrated the impact of sport psychology techniques in allowing athletes to achieve their optimum performance in the face of adversity. The use of mental and behavioral strategies to control feelings of anxiety and low self-efficacy are pivotal for athletes to deliver their best performance under extreme pressure. We consider whether such techniques could improve the preparedness of the newest recruits to the healthcare system, and the impact this could have on patient care. Finally, suggestions for potential research directions within this area are offered to stimulate interest amongst the research community.

Medical Student Perceptions of Feedback and Feedback Behaviors Within the Context of the "Educational Alliance".

PURPOSE: Using the "educational alliance" as a conceptual framework, the authors explored medical students' beliefs about feedback and how their feedback behaviors reflect their perceptions. METHOD: Five focus groups (four to six medical students each) at one UK medical school in 2015 were used to capture and elucidate learners' feedback perceptions and behaviors within the context of the learner-educator relationship. A map of key feedback opportunities across the program was used as a tool for exploring student engagement with the feedback process. Qualitative data were analyzed using an approach based on grounded theory principles. RESULTS: Three learner feedback behaviors emerged: recognizing, using, and seeking feedback. Five core themes influencing these behaviors were generated: learner beliefs, attitudes, and perceptions; relationships; teacher attributes; mode of feedback; and learning culture. Conceptual models illustrating the relationships between the themes and each behavior were developed. Learning culture influenced all three behaviors with a wide context of influences. CONCLUSIONS: Ensuring that feedback leads to improved performance requires more than training educators in best practices. The conceptual models support the educational alliance framework and illustrate the context and complexity of learning culture surrounding the educational relationship, learner, and feedback exchange. The educational alliance approach is underpinned by a mutual understanding of purpose and responsibility. Enhancing learners' feedback literacy skills seems to be the key aspect of the educational alliance in need of attention. Empowering learners to recognize, seek, and use feedback received within diverse learning cultures is essential.

Feedback mapping - The curricular cornerstone of an "educational alliance".

PURPOSE: The "educational alliance" concept articulates a collaborative framework to facilitate effective feedback through transparency of opportunities aligned with learner stage and intended educational outcomes. Using this framework, we evaluated feedback across a 5 year undergraduate medical program to support embedding a successful learner - teacher "educational alliance". METHOD: A comprehensive mapping exercise used an iterative action research process of source documentary analysis, consultations with key curriculum stakeholders and qualitative analysis. The "educational alliance" model provided a critical lens through which to ensure feedback opportunities aligned with intended learning outcomes and developmental progression. RESULTS: Key information about the type, frequency and timing of feedback opportunities was identified within 188 curricular components. The purpose and intended learning outcomes were mapped, aligning with the stage of learning and with an expectation of supporting learners' capacity for self-regulation. This focus providing clear articulation of feedback opportunities supported the longitudinal developmental curricular review, and facilitated enhanced awareness of dialogic feedback within the "educational alliance". CONCLUSIONS: Explicit alignment of learning intentions between learner and educator is key to forming a successful "educational alliance". The feedback map provides clarity ensuring mutual understanding of intended learning outcomes. The iterative process additionally certified feedback aligned with maturing learner developmental needs across the program.

Appreciative inquiry in medical education.

The practice of medicine, and also medical education, typically adopts a problem-solving approach to identify "what is going wrong" with a situation. However, an alternative is Appreciative Inquiry (AI), which adopts a positive and strengths-based approach to identify "what is going well" with a situation. The AI approach can be used for the development and enhancement of the potential of both individuals and organizations. An essential aspect of the AI approach is the generative process, in which a new situation is envisioned and both individual and collective strengths are mobilized to make changes to achieve the valued future situation. The AI approach has been widely used in the world of business and general education, but is has an exciting potential for medical education, including curriculum development, faculty development, supporting learners through academic advising and mentoring, but also for enhancing the teaching and learning of both individuals and groups. This AMEE Guide describes the core principles of AI and their practical application in medical education.

Classifying simulation-based studies using the description, justification and clarification framework: a review of simulation conference abstracts.

Introduction: Simulation-based medical education (SBME) is an accepted learning methodology with an ever-expanding evidence base. Concerns have been expressed that research output in SBME lacks explicit links to educational theory. Using the 'Description, Justification and Clarification' framework we have investigated the extent to which SBME conference abstracts declare the educational theory underpinning their studies. Methods: Abstracts from four major international SBME conferences (for 2014 and 2015) were reviewed. Abstracts were classified using the framework offered by Cook et al who classified studies published in major educational journals. Clarification studies are those which specifically declare and test their underpinning educational approach. Results: We reviewed 1398 conference abstracts which we classified as Description 54.4%, Justification 36.3% and Clarification 9.3%. The two most frequently declared educational theories were Cognitive Theories and Experiential Learning. Conclusion: The low proportion of Clarification studies found in the SBME conference abstracts reflects previous findings highlighting the lack of medical education studies that establish how and why SBME works. Researchers should be encouraged to declare their underpinning educational theories when presenting their work. Conference organisers play an important role in facilitating this through allowing sufficient word count in their submission criteria.

The supervisor's toolkit: A framework for doctoral supervision in health professions education: AMEE Guide No. 104.

Doctoral studies represent a complex undertaking for students and supervisors. Some research describes the experience of students while there are volumes of advice for students considering a doctorate. Yet the terrain for supervisors is less well-trodden and the concept of a pedagogy of supervision is only really starting to emerge. Texts on the doctoral journey from the supervisor's perspective are uncommon and less yet has been written in the context of health professions education. The aim of this Guide, therefore, is to provide guidance for the supervisor's journey, drawing on our collective experience and such literature as there is. We explore the doctoral journey of students and their supervisors, highlighting what the implications are for supervisory practice. Recognising the doctorate as much more than merely conducting a research project, and seeing it as a shared educational endeavour is fundamental to understanding the doctoral journey - a journey that is complex and mutable, constantly shifting as the candidate moves from novice to expert, from dependence to growing autonomy. Our intention is to present this Guide as a toolkit for both the novice and the experienced supervisor as it, on the one hand, seeks to make the practice of supervision more transparent while on the other, challenges the reader to critically reflect on the supervisory space in which they currently reside. Our hope is that the Guide opens up opportunities for generative conversations about the practice of doctoral supervision in health professions education.

A qualitative study of enablers and barriers influencing the incorporation of social accountability values into organisational culture: a perspective from two medical schools.

BACKGROUND: Definitions of social accountability describe the obligation of medical schools to direct education, research and service activities towards addressing the priority health concerns of the population they serve. While such statements give some direction as to how the goal might be reached, it does not identify what factors might facilitate or hinder its achievement. This study set out to identify and explore enablers and barriers influencing the incorporation of social accountability values into medical schools. METHODS: Semi structured interviews of fourteen senior staff in Bar Ilan and Leeds medical schools were undertaken following a literature review. Participants were recruited by purposive sampling in order to identify factors perceived to play a part in the workings of each institution. RESULTS: Academic prestige was seen as a key barrier that was dependent on research priorities and student selection. The role of champions was considered to be vital to tackle staff perceptions and facilitate progress. Including practical community experience for students was felt to be a relevant way in which the curriculum could be designed through engagement with local partners. CONCLUSIONS: Successful adoption of social accountability values requires addressing concerns around potential negative impacts on academic prestige and standards. Identifying and supporting credible social accountability champions to disseminate the values throughout research and education departments in medical and other faculties is also necessary, including mapping onto existing work streams and research agendas. Demonstrating the contribution the institution can make to local health improvement and regional development by a consideration of its economic footprint may also be valuable.

A model of professional self-identity formation in student doctors and dentists: a mixed method study.

BACKGROUND: Professional self-identity [PSI] can be defined as the degree to which an individual identifies with his or her professional group. Several authors have called for a better understanding of the processes by which healthcare students develop their professional identities, and suggested helpful theoretical frameworks borrowed from the social science and psychology literature. However to our knowledge, there has been little empirical work examining these processes in actual healthcare students, and we are aware of no data driven description of PSI development in healthcare students. Here, we report a data driven model of PSI formation in healthcare students. METHODS: We interviewed 17 student doctors and dentists who had indicated, on a tracking questionnaire, the most substantial changes in their PSI. We analysed their perceptions of the experiences that had influenced their PSI, to develop a descriptive model. Both the primary coder and the secondary coder considered the data without reference to the existing literature; i.e. we used a bottom up approach rather than a top down approach. RESULTS: The results indicate that two overlapping frames of reference affect PSI formation: the students' self-perception and their perception of the professional role. They are 'learning' both; neither is static. Underpinning those two learning processes, the following key mechanisms operated: [1] When students are allowed to participate in the professional role they learn by trying out their knowledge and skill in the real world and finding out to what extent they work, and by trying to visualise themselves in the role. [2] When others acknowledge students as quasi-professionals they experience transference and may respond with counter-transference by changing to meet expectations or fulfil a prototype. [3] Students may also dry-run their professional role (i.e., independent practice of professional activities) in a safe setting when invited. CONCLUSIONS: Students' experiences, and their perceptions of those experiences, can be evaluated through a simple model that describes and organises the influences and mechanisms affecting PSI. This empirical model is discussed in the light of prevalent frameworks from the social science and psychology literature.

Supervisor or mentor: is there a difference? Implications for paediatric practice.

The formal roles of educational and clinical supervisor focus on education planning and goal setting against required training elements. Assessment of performance is integral to these roles that necessarily involve some elements of developmental support to trainees. Mentoring is increasingly seen as a desirable route to support doctors in training. Definitions vary, but core expectations of mentors are that they encourage personal development and offer psychosocial support to a trainee within a longitudinal relationship. A key question is whether a supervisor is the appropriate individual to act as a mentor to an individual trainee. The supervisor's role as an assessor of performance can pose challenges and potential conflicts when providing support relating to other personal needs of trainees along their career paths. It is apparent from the literature that mentoring is a multifaceted role, with different actions required of mentors and supervisors. There is evidence that mentorship can affect specialty choice, academic output and commitment to organisations. Addressing the challenges posed by an ideal of providing mentoring to all trainees is potentially as important as ensuring supervisors of competence. The potential benefits for the profession are of enhancing the development and retention of trainees of high calibre within the paediatric discipline.

Developing Enterprise Skills in Undergraduate Medical Students: A Mixed-methods Evaluation.

INTRODUCTION: Support for the development of enterprise skills in medical education exists from the perspectives of educators, researchers, and healthcare leaders. However, literature is limited evaluating the understanding of medical students about these skills. This study aimed to determine whether medical students valued gaining enterprise skills within the course and those skills that they identified and recognized contributed to enterprise practice in subsequent training. METHODOLOGY: Quantitative and qualitative evaluations were undertaken for over three years. Students completed end-of-course evaluations (n = 895) in 2011 and 2012, responding to closed questions utilizing a Likert scale. Subsequent qualitative reflections were collected by interviews one year later with nine students and eight supervisors. RESULTS: Immediately after course completion, students gave positive feedback, identifying the development of independent learning, creativity, and reflection, as these enterprise skills were most valued. However, in subsequent reflection one year later, they were unable to transfer the acquired knowledge and identify the examples of enterprise around them in their later experiences and had mixed beliefs about its value in medicine. CONCLUSION: Enterprise skills need to be revisited explicitly throughout the medical curriculum, with authentic real-life examples, to sustain students' understanding about the role of enterprise in medicine.

How do undergraduate medical students perceive social accountability?

AIM: The concept of social accountability within undergraduate training is embedded within the remit of medical schools. Little is known of how medical students perceive social accountability, recognize aspects of their training contributing to the development of this concept and cultivate the underpinning values. METHODS: Students nearing graduation were recruited to participate in focus groups designed to explore their perceptions of social accountability, which curricular aspects had contributed to their understanding, and to investigate the implications of individual variations in training. RESULTS: Students expressed limited appreciation of the concept of social accountability and acknowledged little explicit teaching around underpinning core concepts such as awareness of local health needs, advocacy and nurturing of altruism. However, participants recognized numerous aspects of the course and learning initiatives as impacting on their attitudes towards this concept implicitly. CONCLUSION: This study highlights areas of their undergraduate training that students recognize as having the greatest impact on their development into socially accountable professionals. It poses some significant challenges for health care educators in addressing unintended consequences, including an outcome-driven educational approach, in reducing students' capacity or willingness to engage in curricular challenges often designed to embed this concept.

How can medical schools contribute to bringing about health equity?

The role of medical schools is in a process of change. The World Health Organization has declared that they can no longer be ivory towers whose primary focus is the production of specialist physicians and cutting edge laboratory research. They must also be socially accountable and direct their activities towards meeting the priority health concerns of the areas they serve. The agenda must be set in partnership with stakeholders including governments, health care organisations and the public. The concept of social accountability has particular resonance for the Bar Ilan Faculty of Medicine in the Galilee, Israel's newest medical school, which was established with a purpose of reducing health inequities in the Region. As a way of exploring and understanding the issues, discussions were held with international experts in the field who visited the Galilee. A symposium involving representatives from other medical schools in Israel was also held to extend the discourse. Deliberations that took place are reported here. The meaning of social accountability was discussed, and how it could be achieved. Three forms of action were the principal foci - augmentation of the medical curriculum, direct action through community engagement and political advocacy. A platform was set for taking the social accountability agenda forward, with the hope that it will impact on health inequalities in Israel and contribute to discussions elsewhere.

Electives in undergraduate medical education: AMEE Guide No. 88.

This Guide outlines the scope and potential roles an elective can contribute to undergraduate medical training and identifies ways to maximize learning opportunities, including within global health. The types of educational activity available for electives range from meeting individual educational need through to exploration of potential career pathways, with many factors influencing choice. Key areas of organization underpinning a successful elective before, during and after the placement include developing clarity of the intended educational outcomes as well as addressing practicalities such as travel and accommodation. Risk management including the implications for the participating schools as well as the student and their elective supervisors is crucial. This Guide would not be complete without some discussion around ethics and professional conduct during an elective, with consideration of the impact of elective placements, particularly in low-middle income countries.

Reflection: moving from a mandatory ritual to meaningful professional development.

Reflection has become established as a key principle underpinning maintenance of standards within professional education and practice. A requirement to evidence reflection within performance review is intended to develop a transformative approach to practice, identify developmental goals, and ultimately, improve healthcare. However, some applications have taken an excessively instrumental approach to the evidencing of reflection, and while they have provided useful templates or framing devices for recording individualistic reflective practice, they potentially have distorted the original intentions. This article revisits the educational theory underpinning the importance of reflection for enhancing performance and considers how to enhance its value within current paediatric practice.

Effectiveness of melatonin for sleep impairment post paediatric acquired brain injury: evidence from a systematic review.

OBJECTIVE: To retrieve and review all the relevant literature describing the administration of melatonin to treat impaired sleep in children following acquired brain injury (ABI). METHODS: A systematic search and retrieval of the literature was conducted using advanced search techniques. The retrieval identified 589 papers, seven of which were relevant. Review/outcomes criteria were developed and study quality was determined. RESULTS: There is paucity of high-quality evidence to support use of melatonin for sleep impairment post paediatric ABI. Variation in dosage, screening and outcome measures, data reporting and a lack of impairment delineation and treatment stratification were recurrent themes. CONCLUSION: Retrieved evidence for the effectiveness of melatonin for post paediatric ABI sleep impairment appears promising. There is a clear need for further study in this area to inform clinical and research practices. Recommendations are given.