Is it possible to introduce an interview to the Korean Medical Licensing Examination to assess professional attributes?: a survey-based observational study

PURPOSE: This study aimed to gather opinions from medical educators on the possibility of introducing an interview to the Korean Medical Licensing Examination (KMLE) to assess professional attributes. Specifically following topics were dealt with: the appropriate timing and tool to assess unprofessional conduct; the possiblity of prevention of unprofessional conduct by introducing an interview to the KMLE; and the possibility of implementation of an interview to the KMLE. METHODS: A cross-sectional study approach based on a survey questionnaire was adopted. We analyzed 104 pieces of news about doctors' unprofessional conduct to determine the deficient professional attributes. We derived 24 items of unprofessional conduct and developed the questionnaire and surveyed 250 members of the Korean Society of Medical Education 2 times. Descriptive statistics, cross-tabulation analysis, and Fisher's exact test were applied to the responses. The answers to the open-ended questions were analyzed using conventional content analysis. RESULTS: In the survey, 49 members (19.6%) responded. Out of 49, 24 (49.5%) responded in the 2nd survey. To assess unprofessional conduct, there was no dominant timing among basic medical education (BME), KMLE, and continuing professional development (CPD). There was no overwhelming assessment tool among written examination, objective structured clinical examination, practice observation, and interview. Response rates of "impossible" (49.0%) and "possible" (42.9%) suggested an interview of the KMLE prevented unprofessional conduct. In terms of implementation, "impossible" (50.0%) was selected more often than "possible" (33.3%). CONCLUSION: Professional attributes should be assessed by various tools over the period from BME to CPD. Hence, it may be impossible to introduce an interview to assess professional attributes to the KMLE, and a system is needed such as self-regulation by the professional body rather than licensing examination.

Evaluating medical students' ability to identify and report errors: finding gaps in patient safety education.

BACKGROUND: Although there are frequent complaints of medical students' incompetence in reporting errors, few studies have examined their error-reporting abilities in the real world. OBJECTIVES: Three sub-functions of self-regulation theory were used to evaluate medical students' ability to identify errors (self-monitoring), analyse root causes (self-judgment), and devise improvement plans (self-reactions). In addition, whether students reacted differently to their errors and those of others (three sub-functions) was also examined. METHODS: A total of 952 patient safety reports were reviewed retrospectively, submitted by third-year medical students between 2016 and 2018. Data were quantitatively and qualitatively analysed to investigate who committed the error, to identify the type of error and its root causes, and to find suggested improvement plans. Chi-square and Fisher's exact tests were used to compare students' responses to error origins. RESULTS: Students reported other errors more frequently than their own (67.6% vs. 32.4%). They reported common critical medical errors, including errors related to engaging with patients (34.5%), invasive procedures (20.2%), and infection (18.5%). The root causes identified were more precise than the improvement plans by the students (75.5% vs. 18.4%, respectively). The students' improvement plans were not practical, especially at the patient level (25.8%). When students committed errors, they considered human factors such as fatigue, scheduling, and training as the most common root cause, focussing on improvement plans at the individual level. CONCLUSIONS: The results suggest that students were good at self-judgment, but not at self-monitoring and self-reactions. They reacted differently, based on who committed the error. To enhance self-regulated learning, Educators should encourage students to confront their errors, reflect on their self-reactions towards errors, develop well-being with time management, and think about the meaning of patient-centredness. Finally, active participation in clinical clerkship longitudinally may provide students with opportunities to learn from their errors.

Negative school experiences of Late Millennial Korean medical students: a qualitative study using the critical incident technique.

PURPOSE: Today's students have distinctive generational characteristics and increased psychopathology and generational tension. The authors investigated the negative experiences of Late Millennial students in medical school to draw implications for student support. METHODS: The authors explored medical students' negative experiences using the critical incident technique. The authors conducted semi-structured in-depth interviews with 13 medical students, between February and May 2016. The authors focused on occurrences that significantly influenced medical students' school lives negatively from the students' perspective. All interviews were recorded and transcribed. The authors classified incidents into frames of reference for the use of faculty development for student support. RESULTS: The authors extracted 22 themes from a total 334 codes and classified them into eight subcategories. Finally, four categories emerged from frames of reference. Students manipulate relationships and colluding for better specialty choice. They experience uncontrolled rifts in interpersonal relationships between peers including lawsuits, sexual assaults, and social network service conflicts. Today's students feel resentment towards dependent hierarchical relationships with seniors. They struggle with gender discrimination but perpetuate outdated gender role toward the opposite gender. CONCLUSION: Faculty members should understand today's students' level of career stress and desire for work life balance. They should motivate students' professional identity, promote assertiveness against unfair authorities, and focus on mental health, teamwork, and relationship building. All generations need to understand other generations and develop appropriate leadership and gender sensitivity.

Medical education trends for future physicians in the era of advanced technology and artificial intelligence: an integrative review.

BACKGROUND: Medical education must adapt to different health care contexts, including digitalized health care systems and a digital generation of students in a hyper-connected world. The aims of this study are to identify and synthesize the values that medical educators need to implement in the curricula and to introduce representative educational programs. METHODS: An integrative review was conducted to combine data from various research designs. We searched for articles on PubMed, Scopus, Web of Science, and EBSCO ERIC between 2011 and 2017. Key search terms were "undergraduate medical education," "future," "twenty-first century," "millennium," "curriculum," "teaching," "learning," and "assessment." We screened and extracted them according to inclusion and exclusion criteria from titles and abstracts. All authors read the full texts and discussed them to reach a consensus about the themes and subthemes. Data appraisal was performed using a modified Hawker 's evaluation form. RESULTS: Among the 7616 abstracts initially identified, 28 full-text articles were selected to reflect medical education trends and suggest suitable educational programs. The integrative themes and subthemes of future medical education are as follows: 1) a humanistic approach to patient safety that involves encouraging humanistic doctors and facilitating collaboration; 2) early experience and longitudinal integration by early exposure to patient-oriented integration and longitudinal integrated clerkships; 3) going beyond hospitals toward society by responding to changing community needs and showing respect for diversity; and 4) student-driven learning with advanced technology through active learning with individualization, social interaction, and resource accessibility. CONCLUSIONS: This review integrated the trends in undergraduate medical education in readiness for the anticipated changes in medical environments. The detailed programs introduced in this study could be useful for medical educators in the development of curricula. Further research is required to integrate the educational trends into graduate and continuing medical education, and to investigate the status or effects of innovative educational programs in each medical school or environment.

Understanding medical students' empathy based on Enneagram personality types.

PURPOSE: High self-awareness can promote communication and empathy. The Enneagram is a well-known personality tool to enhance self-awareness. We evaluated differences in empathy among medical students using the Enneagram typology. METHODS: This cross-sectional study included first and second grade students at the Inje University College of Medicine. The Jefferson Scale of Empathy was used to measure empathy and the Korean Enneagram Personality Type Indicator was used for examining personality characteristics. Empathy scores were analyzed according to the Triads, Hornevian group, Harmonic group, and each Enneagram type. RESULTS: The Instinctive triad, the Withdrawns, and the Positive outlook group were the most common, and the Feeling triad, the Assertives, and the Emotional realness group were the least common. Students in the Feeling triad and the Dutifuls had higher compassionate care (CC) scores as compared to their counterparts. Type 2 and 6 students showed the two highest empathy and CC scores. The empathy score of type 3 students was the lowest. Type 7 had the lowest CC score but the highest perspective taking score. CONCLUSION: These differences in empathy according to Enneagram personality types can be applied to medical education to maintain and improve medical students' empathy.

Medical students interact with multicultural patients to learn cultural diversity.

PURPOSE: The aim was to present our experiences implementing a cultural diversity (CD) education program. METHODS: The authors held a 4-hour CD class for third-year medical students. The aim of the class was to facilitate students to realize and reflect on the importance of CD on healthcare delivery in Korea. The class was comprised of an orientation about CD in Korea, physicians and multicultural guests sharing their experiences with students, small group discussion, and Q&A panel with multicultural guests. Students provided written feedback for program evaluation. Authors classified their comments qualitatively. RESULTS: Students mostly responded positively to the class with a significant focus on interacting with the multicultural guests. Students realized the significance of CD in healthcare and reflected deeply on their discussion with the multicultural patients. Students needed more time to interact with multicultural guests from a greater range of cultures represented in Korea. Most did not need English interpretation. CONCLUSION: The aim of the class was achieved. Medical students' interaction with multicultural patients may promote the students' understanding and reflection about CD in health care.

Medical students' clinical performance of dealing with patients in the context of domestic violence.

PURPOSE: The aim of this study was to inquire about the clinical performance and determine the performance pattern of medical students in standardized patient (SP) based examinations of domestic violence (DV). METHODS: The clinical performance sores in DV station with SP of third-year (n=111, in 2014) and 4th-year (n=143, in 2016) medical students of five universities in the Busan-Gyeongnam Clinical Skills Examination Consortium were subjected in this study. The scenarios and checklists of DV cases were developed by the case development committee of the consortium. The students' performance was compared with other stations encountered in SP. The items of the checklists were categorized to determine the performance pattern of students investigating DV into six domains: disclosure strategy (D), DV related history taking (H), checking the perpetrator's psychosocial state (P), checking the victim's condition (V), negotiating and persuading the interviewee (N), and providing information about DV (I). RESULTS: Medical students showed poorer performance in DV stations than in the other stations with SP in the same examination. Most students did confirm the perpetrator and commented on confidentiality but ignored the perpetrator's state and patient's physical and psychological condition. The students performed well in the domains of D, H, and I but performed poorly in domains P, V, and N. CONCLUSION: Medical students showed poor clinical performance in the DV station. They performed an 'event oriented interview' rather than 'patient centered' communication. An integrated educational program of DV should be set to improve students' clinical performance.

Authenticity, acceptability, and feasibility of a hybrid gynecology station for the Papanicolaou test as part of a clinical skills examination in Korea.

PURPOSE: The objective of this study was to evaluate the authenticity, acceptability, and feasibility of a hybrid station that combined a standardized patient encounter and a simulated Papanicolaou test. METHODS: We introduced a hybrid station in the routine clinical skills examination (CSE) for 335 third-year medical students at 4 universities in Korea from December 1 to December 3, 2014. After the tests, we conducted an anonymous survey on the authenticity, acceptability, and feasibility of the hybrid station. RESULTS: A total of 334 medical students and 17 professors completed the survey. A majority of the students (71.6%) and professors (82.4%) agreed that the hybrid station was more authentic than the standard CSE. Over 60 percent of the students and professors responded that the station was acceptable for assessing the students' competence. Most of the students (75.2%) and professors (82.4%) assessed the required tasks as being feasible after reading the instructions. CONCLUSION: Our results showed that the hybrid CSE station was a highly authentic, acceptable, and feasible way to assess medical students' performance.

Verbal communication of students with high patient-physician interaction scores in a clinical performance examination assessed by standardized patients.

PURPOSE: Standardized patients (SPs) tend to rate medical students' communication skills subjectively and comprehensively, in contrast to such objective skill set defined in the clinical performance examination (CPX). Meanwhile, medical school instructors have a different approach in their evaluation of students' communication skills. We aim to analyze medical students' verbal communication skills using objective methods, and to determine the contributing factors of a patient-physician interaction (PPI) score. METHODS: Students with high- and low-ranking scores for PPI in CPX were selected. The Roter interaction analysis system was used to compare verbal communication behaviors of the students and SPs. Patient-centeredness scores (PCSs), physician's verbal dominance, and number of utterances were compared between the two groups. RESULTS: PCSs and physician's verbal dominance had no difference between the groups. The number of utterances during the limited time of 5 minutes of CPX was higher for the high-ranking students. They tended to employ more paraphrase/check for understanding, and closed questions for psychosocial state and open questions for medical condition. The SPs interviewed by high-ranking students gave more medical information and requested for more services. CONCLUSION: In the case of the routine checkup, smooth conversations with more frequent utterances were detected in the high-ranking students. More medical information exchange and requests for services by SPs were higher for the high-ranking students. Medical communication instructors should keep in mind that our results could be indicators of a high PPI score.

Research trends in studies of medical students' characteristics: a scoping review.

The purpose of this study is to investigate domestic and international research trends in studies of medical students' characteristics by using the scoping review methods. This study adopted the scoping review to assess papers on the characteristics of medical students. The procedure of research was carried out according to the five steps of the scoping review. The full texts of 100 papers are obtained and are read closely, after which suitable 88 papers are extracted by us for this research. The review is mapped by the year of the study, source, location, author, research design, research subject, objective, and key results. The frequency is analyzed by using Microsoft Excel and SPSS. We found 70 papers (79.5%) on a single medical school, 15 (17.0%) on multiple medical schools, and three (3.4%) on mixed schools, including medical and nonmedical schools. Sixty-nine (79.5%) were cross-sectional studies and 18 (20.5%) were longitudinal studies. Eighty-two papers (93.2%) adopted questionnaire surveys. We summarized research trends of studies on medical students in Korea and overseas by topic, and mapped them into physical health, mental health, psychological characteristics, cognitive characteristics, social characteristics, and career. This study provides insights into the future directions of research for the characteristics of medical students.

Using standardized patients versus video cases for representing clinical problems in problem-based learning.

PURPOSE: The quality of problem representation is critical for developing students' problem-solving abilities in problem-based learning (PBL). This study investigates preclinical students' experience with standardized patients (SPs) as a problem representation method compared to using video cases in PBL. METHODS: A cohort of 99 second-year preclinical students from Inje University College of Medicine (IUCM) responded to a Likert scale questionnaire on their learning experiences after they had experienced both video cases and SPs in PBL. The questionnaire consisted of 14 items with eight subcategories: problem identification, hypothesis generation, motivation, collaborative learning, reflective thinking, authenticity, patient-doctor communication, and attitude toward patients. RESULTS: The results reveal that using SPs led to the preclinical students having significantly positive experiences in boosting patient-doctor communication skills; the perceived authenticity of their clinical situations; development of proper attitudes toward patients; and motivation, reflective thinking, and collaborative learning when compared to using video cases. The SPs also provided more challenges than the video cases during problem identification and hypotheses generation. CONCLUSION: SPs are more effective than video cases in delivering higher levels of authenticity in clinical problems for PBL. The interaction with SPs engages preclinical students in deeper thinking and discussion; growth of communication skills; development of proper attitudes toward patients; and motivation. Considering the higher cost of SPs compared with video cases, SPs could be used most advantageously during the preclinical period in the IUCM curriculum.

A pilot study on the evaluation of medical student documentation: assessment of SOAP notes.

PURPOSE: The purpose of this study was evaluation of the current status of medical students' documentation of patient medical records. METHODS: We checked the completeness, appropriateness, and accuracy of 95 Subjective-Objective-Assessment-Plan (SOAP) notes documented by third-year medical students who participated in clinical skill tests on December 1, 2014. Students were required to complete the SOAP note within 15 minutes of an standard patient (SP)-encounter with a SP complaining rhinorrhea and warring about meningitis. RESULTS: Of the 95 SOAP notes reviewed, 36.8% were not signed. Only 27.4% documented the patient's symptoms under the Objective component, although all students completed the Subjective notes appropriately. A possible diagnosis was assessed by 94.7% students. Plans were described in 94.7% of the SOAP notes. Over half the students planned workups (56.7%) for diagnosis and treatment (52.6%). Accurate documentation of the symptoms, physical findings, diagnoses, and plans were provided in 78.9%, 9.5%, 62.1%, and 38.0% notes, respectively. CONCLUSION: Our results showed that third-year medical students' SOAP notes were not complete, appropriate, or accurate. The most significant problems with completeness were the omission of students' signatures, and inappropriate documentation of the physical examinations conducted. An education and assessment program for complete and accurate medical recording has to be developed.

Assessing clinical reasoning abilities of medical students using clinical performance examination.

PURPOSE: The purpose of this study is to investigate the reliability and validity of new clinical performance examination (CPX) for assessing clinical reasoning skills and evaluating clinical reasoning ability of the students. METHODS: Third-year medical school students (n=313) in Busan-Gyeongnam consortium in 2014 were included in the study. One of 12 stations was developed to assess clinical reasoning abilities. The scenario and checklists of the station were revised by six experts. Chief complaint of the case was rhinorrhea, accompanied by fever, headache, and vomiting. Checklists focused on identifying of the main problem and systematic approach to the problem. Students interviewed the patient and recorded subjective and objective findings, assessments, plans (SOAP) note for 15 minutes. Two professors assessed students simultaneously. We performed statistical analysis on their scores and survey. RESULTS: The Cronbach α of subject station was 0.878 and Cohen κ coefficient between graders was 0.785. Students agreed on CPX as an adequate tool to evaluate students' performance, but some graders argued that the CPX failed to secure its validity due to their lack of understanding the case. One hundred eight students (34.5%) identified essential problem early and only 58 (18.5%) performed systematic history taking and physical examination. One hundred seventy-three of them (55.3%) communicated correct diagnosis with the patient. Most of them had trouble in writing SOAP notes. CONCLUSION: To gain reliability and validity, interrater agreement should be secured. Students' clinical reasoning skills were not enough. Students need to be trained on problem identification, reasoning skills and accurate record-keeping.

A Scoping Review: Communication Between Emergency Physicians and Patients in the Emergency Department.

BACKGROUND: Understanding the basic qualities of communication between emergency physicians and patients could improve communication in the emergency department. OBJECTIVE: The objectives of this scoping review are to map the literature about the gaps in communication between emergency physicians and patients in the emergency department and make recommendations for further research. METHODS: A scoping review of literature published since 1980 and written in English was undertaken using the following databases: Pubmed, Scopus, and SocINDEX. The articles were searched for using two-keyword combinations of the following keywords joined by "AND": "communication," "patient," "emergency physician," "emergency department/emergency room/accident," and "emergency room." Seventeen articles were included in the final review. RESULTS: Five research issues were covered by the 17 papers: patient-centered communication, information sharing, bad news delivery, shared decision making, and physicians' perspectives on communication. Emergency physicians have several communication characteristics: doctor-driven decision making, focusing on efficient information gathering, immature communication techniques, and obstacles to overcoming miscommunication. Patients also have several communication characteristics: active participation in medical encounters, expectation of physician as a reliable guide, understanding physicians' difficulties, and factors that contribute to understanding. CONCLUSIONS: Several conclusions about emergency department communication between patients and emergency physicians were drawn. Additional research is required to consider diverse patient needs in the emergency department. Furthermore, training programs for emergency physicians to improve the quality of communication should be developed and implemented in line with our research findings.

[Development of guide to clinical performance and basic clinical skills for medical students].

The aim of this report was to discuss the development and content of a guide on clinical performance and basic clinical skills for medical students. We published the first edition of this guide in 2010 and will publish the second edition in 2016. Initially, we took a survey on important clinical presentations and fundamental clinical and technical skills in 41 medical schools in Korea. Ultimately, we chose 80 core clinical presentations and 56 clinical skills. In the guide to basic clinical skills, we described the physical examination and technical skills according to the preprocedural preparation, procedure, and postprocedural process. In the guide on clinical performance, we reviewed patient encounters-from history taking and the physical examination to patient education. We included communication skills, principles of patient safety, and clinical reasoning schemes into the guides. In total, 43 academic faculty members helped develop the basic clinical skills guide, 75 participated in establishing the clinical performance guide, and 16 advisors from 14 medical specialty societies contributed to the guide. These guides can help medical students approach patients holistically and safely.

[Development of a portfolio for competency-based assessment in a clinical clerkship curriculum].

The purpose of this report was to describe our experience in planning and developing a portfolio for a clinical clerkship curriculum. We have developed a portfolio for assessing student competency since 2007. During an annual workshop on clinical clerkship curricula, clerkship directors from five Paik hospitals of Inje University met to improve the assessment of the portfolio. We generated templates for students to record their activities and reflection and receive feedback. We uploaded these templates to our school's website for students to download freely. Annually, we have held a faculty development seminar and a workshop for portfolio assessment and feedback. Also, we established an orientation program on how to construct a learning portfolio for students. Future actions include creating a ubiquitous portfolio system, extending the portfolio to the entire curriculum, setting up an advisor system, and managing the quality of the portfolio. This study could be helpful for medical schools that plan to improve their portfolio assessment with an outcome-based approach.

The relationships between empathy, stress and social support among medical students.

OBJECTIVE: To examine the relationship between stress, social support, and empathy among medical students. METHODS: We evaluated the relationships between stress and empathy, and social support and empathy among medical students. The respondents completed a questionnaire including demographic information, the Jefferson Scale of Empathy, the Perceived Stress Scale, and the Multidimensional Scale of Perceived Social Support. Correlation and linear regression analyses were conducted, along with sub-analyses according to gender, admission system, and study year. RESULTS: In total, 2,692 questionnaires were analysed. Empathy and social support positively correlated, and empathy and stress negatively correlated. Similar correlation patterns were detected in the sub-analyses; the correlation between empathy and stress among female students was negligible. In the regression model, stress and social support predicted empathy among all the samples. In the sub-analysis, stress was not a significant predictor among female and first-year students. CONCLUSIONS: Stress and social support were significant predictors of empathy among all the students. Medical educators should provide means to foster resilience against stress or stress alleviation, and to ameliorate social support, so as to increase or maintain empathy in the long term. Furthermore, stress management should be emphasised, particularly among female and first-year students.

Medical students' agenda-setting abilities during medical interviews.

PURPOSE: Identifying patients' agendas is important; however, the extent of Korean medical students' agenda-setting abilities is unknown. The study aim was to investigate the patterns of Korean medical students' agenda solicitation. METHODS: A total of 94 third-year medical students participated. One scenario involving a female patient with abdominal pain was created. Students were video-recorded as they interviewed the patient. To analyze whether students identify patients' reasons for visiting, a checklist was developed based on a modified version of the Calgary-Cambridge Guide to the Medical Interview: Communication Process checklist. The duration of the patient's initial statement of concerns was measured in seconds. The total number of patient concerns expressed before interruption and the types of interruption effected by the medical students were determined. RESULTS: The medical students did not explore the patients' concerns and did not negotiate an agenda. Interruption of the patient's opening statement occurred in 4.62±2.20 seconds. The most common type of initial interruption was a recompleter (79.8%). Closed-ended questions were the most common question type in the second and third interruptions. CONCLUSION: Agenda setting should be emphasized in the communication skills curriculum of medical students. The Korean Clinical Skills Exam must assess medical students' ability to set an agenda.

Feasibility of implementing a surgical student internship program in South Korea.

PURPOSE: Despite recommendations for introducing student internships (SI) in undergraduate medical education in Korea, the feasibility of surgical SIs has not been demonstrated in the Korean context. We thus identified tasks that could be performed by surgical student interns in a Korean education hospital. METHODS: The opinions of surgery clerkship directors of medical schools nationwide, regarding the tasks, symptoms and signs, disease entities, and procedures that student interns could perform in their hospitals, were subjected to descriptive analysis. RESULTS: Out of the 41 medical schools in Korea, 32 responded. Five implemented an optimal-quality SI program. Two schools considered third-year clerkship as SI. The respondents replied that student interns could be involved in basic nonspecific tasks such as history taking, physical examination, medial recording, reporting patients' status, and assisting during surgery. However, more surgery-specific tasks such as perioperative management or caring for a patient with acute abdominal pain were considered difficult for student interns to encounter in the Korean context. CONCLUSION: Surgical educators should determine a specific role for student interns and encourage them to perform surgery-specific tasks. We recommend societal and system support, and curriculum renovation to establish an SI program in Korea.