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1.
Acad Med ; 95(2): 293-300, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31348059

RESUMO

PURPOSE: The rise of coaching programs in medical education sparks questions about ways to support physician coaches in learning new educational practices specific to coaching. How coaches learn from one another is of particular interest considering the potential value of social learning. Using communities of practice as a conceptual framework, the authors examine the sense of community and relationships among coaches in a new medical student coaching program, the value of this community, and the facilitators and barriers influencing community development. METHOD: In this qualitative study, investigators conducted 34 interviews with physician coaches at 1 institution over 2 years (2017-2018) and observed 36 coach meetings. Investigators analyzed interview transcripts using thematic analysis and used observation field notes for context and refinement of themes. RESULTS: Coaches described a sense of community based on regular interactions; shared commitment to medical education; and new roles with similar experiences, joys, and challenges. They valued the sense of camaraderie and support, learning from one another, and opportunities for professional growth that strengthened their identities as educators and enhanced job satisfaction. Facilitators of community included regular meetings, leadership and administrative support, and informal opportunities to interact outside of meetings. Barriers included time constraints and geographic challenges for coaches at off-site locations. CONCLUSIONS: The sense of community among coaches was a valued and beneficial part of their coaching experience. Coaches' interactions and relationships promoted skill acquisition, knowledge transfer, professional development, and career satisfaction. Thus, incorporating support for social learning in coaching programs promotes coach faculty development.

2.
Acad Med ; 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31577592

RESUMO

PURPOSE: Feedback is important for medical students' development. Recent conceptualizations of feedback as a dialogue between feedback provider and recipient point to longitudinal relationships as a facilitator of effective feedback discussions. This study illuminates how medical students experience feedback within a longitudinal relationship with a physician coach. METHOD: In this qualitative study, second-year medical students from University of California, San Francisco participated in semistructured interviews that explored their experiences discussing feedback within longitudinal, nonevaluative coaching relationships. Interviews occurred between May and October 2018. Interview questions addressed students' experiences receiving feedback from their coach, how and when they used this feedback, and how their relationship with their coach influenced engagement in feedback discussions. Interviews were analyzed using constructivist grounded theory. RESULTS: Seventeen students participated. The authors identified 3 major themes. First, students' development of a feedback mind-set: Over time, students came to view feedback as an invaluable component of their training. Second, setting the stage for feedback: Establishing feedback routines and a low-stakes environment for developing clinical skills were important facilitators of effective feedback discussions. Third, interpreting and acting upon feedback: Students described identifying, receiving, and implementing tailored and individualized feedback in an iterative fashion. As students gained comfort and trust in their coaches' feedback, they reported increasingly engaging in feedback conversations for learning. CONCLUSIONS: Through recurring feedback opportunities and iterative feedback discussions with coaches, students came to view feedback as essential for growth and learning. Longitudinal coaching relationships can positively influence how students conceptualize and engage in feedback discussions.

4.
J Gen Intern Med ; 34(5): 662-668, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30993622

RESUMO

BACKGROUND: Trust informs supervision decisions in medical training. Factors that influence trust differ depending on learners' and supervisors' level. Research has focused on resident trainees; questions exist about how medical students experience entrustment. OBJECTIVE: This study examines how clerkship students perceive supervisors' trust in them and its impact on their learning. DESIGN: Qualitative study using individual semi-structured interviews. PARTICIPANTS: Clerkship medical students at the University of California, San Francisco. APPROACH: We invited 30 core clerkship students to participate in interviews (October 2017 to February 2018) eliciting examples of appropriate, over-, and under-trust. We coded and analyzed transcripts using thematic analysis. KEY RESULTS: Sixteen (53%) students participated. Three major themes arose: trust as scaffolding for learning, effects of trust on the learning environment, and consequences of trust for patients. Appropriate trust usually involved coaching and close guidance, often with more junior supervisors (interns or residents). These situations fostered students' motivation to learn, sense of value on the team, and perceived benefits to patients. Over-trust was characterized by task assignment without clear instruction, supervision, or feedback. Over-trust prompted student anxiety and stress, and concerns for potential patient harm. Under-trust was characterized by lack of clarity about the student role, leading to frustration and discontent, with unclear impact on patients. Students attributed inappropriate trust to contextual and supervisor factors and did not feel empowered to intervene due to concerns about performance evaluations and hierarchy. CONCLUSIONS: As early learners in the clinical workplace, students frame trust as entailing high levels of support. It is important for medical educators to consider ways to train resident and faculty supervisors to enact trust and supervision for students differently than for residents. Structures that encourage students and supervisors to discuss trust and supervision in a transparent way can enhance learning.

5.
Teach Learn Med ; 30(4): 367-376, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29509038

RESUMO

Phenomenon: Preclerkship medical education has undergone extensive reform, and the clerkship years are growing targets for curricular innovation. As institutions implement new preclerkship curricula to better prepare medical students to practice medicine in the context of modern healthcare systems, the perspective of clerkship leaders regarding clerkship student roles and potential for change will facilitate redefining these roles so that preclerkship educational innovations can continue into clerkships. Approach: In this qualitative exploratory study, authors conducted semistructured interviews with clerkship and site directors for eight core clerkships from April to May 2016. Questions addressed how clerkship leaders perceive current student roles and the potential for change. Through iterative consensus building, authors identified themes describing current ideal clerkship student roles applicable to future roles. Findings: Twenty-three of 24 (96%) directors participated. Findings fell into four themes: factors influencing the clerkship role, clerkship student role archetypes, workplace authenticity and value, and potential for change. Student, supervisor, and context factors determine the clerkship student role. Three role archetypes emerged: the apprentice (an assistant completing concrete patient care tasks), the academic (a researcher bringing literature back to the team), and the communicator (an interdisciplinary and patient liaison). Each archetype was considered authentic and valuable. Positive attitudes toward preclerkship curricular changes were associated with openness to evolution of the clerkship students' role. These emerging roles mapped to the archetypes. Insights: Clerkship leaders perceive that student, supervisor, and context factors result in varying emphasis on role archetypes, which in turn lead to different types of learning. Medical educators can use the archetypes to articulate how expanded student roles align learning with clinical needs, particularly as they relate to health systems science and inquiry.


Assuntos
Estágio Clínico , Currículo , Reforma dos Serviços de Saúde , Estudantes de Medicina , Educação de Graduação em Medicina , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pesquisa Qualitativa
8.
Acad Med ; 92(9): 1320-1327, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28079727

RESUMO

PURPOSE: Appropriate trust and supervision facilitate trainees' growth toward unsupervised practice. The authors investigated how supervisor experience influences trust, supervision, and subsequently trainee learning. METHOD: In a two-phase qualitative inductive content analysis, phase one entailed reviewing 44 internal medicine resident and attending supervisor interviews from two institutions (July 2013 to September 2014) for themes on how supervisor experience influences trust and supervision. Three supervisor exemplars (early, developing, experienced) were developed and shared in phase two focus groups at a single institution, wherein 23 trainees validated the exemplars and discussed how each impacted learning (November 2015). RESULTS: Phase one: Four domains of trust and supervision varying with experience emerged: data, approach, perspective, clinical. Early supervisors were detail oriented and determined trust depending on task completion (data), were rule based (approach), drew on their experiences as trainees to guide supervision (perspective), and felt less confident clinically compared with more experienced supervisors (clinical). Experienced supervisors determined trust holistically (data), checked key aspects of patient care selectively and covertly (approach), reflected on individual experiences supervising (perspective), and felt comfortable managing clinical problems and gauging trainee abilities (clinical). Phase two: Trainees felt the exemplars reflected their experiences, described their preferences and learning needs shifting over time, and emphasized the importance of supervisor flexibility to match their learning needs. CONCLUSIONS: With experience, supervisors differ in their approach to trust and supervision. Supervisors need to trust themselves before being able to trust others. Trainees perceive these differences and seek supervision approaches that align with their learning needs.


Assuntos
Educação de Pós-Graduação em Medicina , Medicina Interna/educação , Internato e Residência , Relações Interprofissionais , Aprendizagem , Confiança , Adulto , Atitude do Pessoal de Saúde , Competência Clínica , Feminino , Grupos Focais , Humanos , Entrevistas como Assunto , Masculino , Pesquisa Qualitativa
9.
Med Teach ; 39(5): 558-559, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-27924665

RESUMO

This Personal View about feedback culture is based on our personal experiences as internal medicine chief residents with attendings, residents, and interns who came into our office to discuss concerns about team members. Our unique perspective as chief residents revealed a tendency amongst physicians at all levels of training to first raise these concerns behind closed doors, instead of with the learner directly. We highlight the need to shift feedback culture in medical training away from this practice towards a clinical "micro-coaching" approach.


Assuntos
Retroalimentação , Medicina Interna/educação , Internato e Residência , Competência Clínica , Humanos
10.
J Health Care Poor Underserved ; 27(3): 961-70, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27524745

RESUMO

INTRODUCTION: Research has shown that student-run clinics (SRCs) are ideal experiential learning arenas for medical students, but no studies have characterized the impact of SRC participation on premedical students. METHODS: We conducted a retrospective cohort study with newly matriculated first-year medical students at five California medical schools to determine the impact of premedical involvement in SRCs. Participants completed an anonymous one-time online survey that included demographic information and questions regarding SRC involvement prior to medical school. RESULTS: Two-hundred eighty-seven out of 588 (48.2%) newly matriculated first-year medical students responded, with 17.4% of respondents reporting that they had volunteered in SRCs prior to medical school. These students identified SRCs as meaningful venues for developing patient interaction skills and finding medical student and physician mentors. DISCUSSION: Prior to medical school matriculation, SRC experiences may be important experiential learning arenas, providing premedical students with an authentic clinical setting and access to mentors.


Assuntos
Instituições de Assistência Ambulatorial , Estudantes de Medicina , Estudantes Pré-Médicos , California , Humanos , Estudos Retrospectivos , Faculdades de Medicina
12.
Acad Med ; 91(10): 1406-1415, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26983076

RESUMO

PURPOSE: Although residents trust interns to provide patient care, little is known about how trust forms. METHOD: Using a multi-institutional mixed-methods study design, the authors interviewed (March-September 2014) internal medicine (IM) residents in their second or third postgraduate year at a single institution to address how they develop trust in interns. Transcript analysis using grounded theory yielded a model for resident trust. Authors tested (January-March 2015) the model with residents from five IM programs using a two-section quantitative survey (38 items; 31 rated 0 = not at all to 100 = very much; 7 rated 0 = strongly disagree to 100 = strongly agree) to identify influences on how residents form trust. RESULTS: Qualitative analysis of 29 interviews yielded 14 themes within five previously identified factors of trust (resident, intern, relationship, task, and context). Of 478 residents, 376 (78.7%) completed the survey. Factor analysis yielded 11 factors that influence trust. Respondents rated interns' characteristics (reliability, competence, and propensity to make errors) highest when indicating importance to trust (respective means 86.3 [standard deviation = 9.7], 76.4 [12.9], and 75.8 [20.0]). They also rated contextual factors highly as influencing trust (access to an electronic medical record, duty hours, and patient characteristics; respective means 79.8 [15.3], 73.1 [14.4], and 71.9 [20.0]). CONCLUSIONS: Residents form trust based on primarily intern- and context-specific factors. Residents appear to consider trust in a way that prioritizes interns' execution of essential patient care tasks safely within the complexities and constraints of the hospital environment.

13.
J Hosp Med ; 10(5): 307-10, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25755159

RESUMO

BACKGROUND: Poor communication between hospitalists and outpatient physicians can contribute to adverse events after discharge. Electronic medical records (EMRs) shared by inpatient and outpatient clinicians offer primary care providers (PCPs) better access to information surrounding a patient's hospitalization. However, the PCP experience and subsequent expectations for discharge communication within a shared EMR are unknown. METHODS: We surveyed PCPs 1 year after a shared EMR was implemented at our institution to assess PCP satisfaction with current discharge communication practices and identify areas for improvement. RESULTS: Seventy-five of 124 (60%) clinicians completed the survey. Although most PCPs reported receiving automated discharge notifications (71%), only 39% felt that notifications plus discharge summaries were adequate for safe transitions of care. PCPs expressed that complex hospitalizations necessitated additional communication via e-mail or telephone; only 31% reported receiving such communication. The content most important in additional communication included medication changes, follow-up actions, and active medical issues. CONCLUSIONS: Despite optimized access to information provided by a shared EMR, only 52% of PCPs were satisfied with current discharge communication. PCPs express a continued need for high-touch communication for safe transitions of care. Further standardization of discharge communication practices is necessary.


Assuntos
Comunicação , Registros Eletrônicos de Saúde/organização & administração , Médicos Hospitalares , Alta do Paciente , Médicos de Atenção Primária , Atitude do Pessoal de Saúde , Humanos , Relações Interprofissionais
14.
Clin Respir J ; 9(4): 436-42, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24799125

RESUMO

BACKGROUND AND AIMS: The epidemiology of non-tuberculous mycobacteria (NTM) infection is not well defined. We evaluated the trends in incidence of NTM infections at San Francisco General Hospital (SFGH), a large metropolitan county hospital. METHODS: We performed a retrospective review of microbiologic and clinical records of all patients with a positive NTM culture reported from 1993 to 2001. NTM infection was defined by the isolation of >1 NTM from any clinical specimen. Patients were stratified by human immunodeficiency virus (HIV) status. Univariate and multivariate logistic regression were used to identify factors that were independently associated with NTM infection. Trends over time were assessed using Poisson test for trend. RESULTS: During the study period, 25 736 samples from 7395 patients were cultured for mycobacteria. Of these samples, 2853 (11.1%) from 1345 patients (18.2%) were culture positive for NTM. Patient characteristics associated with infection included younger age (P < 0.001), male gender (P < 0.001), White ethnicity compared with Asian and Hispanic (P < 0.001 and P = 0.01, respectively), and HIV positivity (P < 0.001). Overall, NTM infection at SFGH decreased significantly from 319 cases in 1993 to 59 in 2001 (P < 0.001). Mycobacterium avium was predominant in both HIV-positive and HIV-negative populations (74.5% and 44.6% of isolates, respectively), and Mycobacterium kansasii was the second most common NTM species isolated. The proportion of other NTM species isolated in these groups differed. CONCLUSION: In contrast to other published studies, time-series analyses show that NTM isolation rates decreased during the study period at SFGH, where NTM was most strongly associated with HIV infection.


Assuntos
Infecções por HIV/epidemiologia , Infecções por Micobactéria não Tuberculosa/epidemiologia , Adulto , Feminino , Infecções por HIV/microbiologia , Hospitais Gerais , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infecções por Micobactéria não Tuberculosa/etnologia , Infecções por Micobactéria não Tuberculosa/microbiologia , Infecções por Micobactéria não Tuberculosa/virologia , Mycobacterium kansasii/isolamento & purificação , Mycobacterium xenopi/isolamento & purificação , Estudos Retrospectivos , São Francisco/epidemiologia
16.
Med Educ ; 48(2): 136-45, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24528396

RESUMO

OBJECTIVES: Given the calls for earlier student engagement in clinical experiences, educators are challenged to define roles for pre-clerkship students that enable legitimate participation in clinical practice. This study aimed to determine the student roles and activities, as well as the clinic characteristics, that allow early student engagement within a specific clinical experience. METHODS: The authors conducted semi-structured interviews in December 2011 and January 2012 with a purposive sample of medical student and faculty volunteers at student-run clinics (SRCs). They were asked to discuss and compare student roles in SRCs with those in the core curriculum. An inductive approach and iterative process were used to analyse the interview transcripts. Themes identified from initial open coding were organised using the sensitising concepts of workplace learning and communities of practice and subsequently applied to code all transcripts. RESULTS: A total of 22 medical students and four faculty advisors were interviewed. Thematic analysis revealed pre-clerkship student roles in direct patient care (patient triage, history and physical examinations, patient education, laboratory and immunisation procedures) and in clinic management (patient follow-up, staff management, quality improvement). Students took ownership of patients and occupied central roles in the function of the clinic, with faculty staff serving as peripheral resources. Clinic-related features supporting this degree of legitimate participation included defined scopes of practice, limited presenting illnesses, focused student training, and clear protocols and operations manuals. CONCLUSIONS: Pre-clerkship students are capable of legitimately participating in patient care experiences to an extent not usually available to them. The SRC represents one example of how early clinical experiences in the core curriculum might be transformed through the provision of patient care activities of narrow scope.


Assuntos
Assistência Ambulatorial/organização & administração , Educação de Graduação em Medicina/métodos , Papel (figurativo) , Estudantes de Medicina , Competência Clínica , Currículo , Docentes de Medicina , Acesso aos Serviços de Saúde , Humanos , Cultura Organizacional , Assistência ao Paciente , Relações Médico-Paciente , Aprendizagem Baseada em Problemas/organização & administração , Pesquisa Qualitativa , Voluntários , Local de Trabalho/organização & administração
17.
Acad Med ; 88(6): 831-6, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23619068

RESUMO

PURPOSE: Student-run clinics (SRCs) provide preclerkship medical students with systems-based practice (SBP) experiences as they engage in patient care and manage clinic operations. This study explored the types and context of SBP activities students participate in at SRCs. METHOD: Between November 2011 and February 2012, the authors conducted in-depth, semistructured interviews with a purposive sample of medical students who served as volunteers and coordinators (student leadership role) at four independently run SRCs within the University of California, San Francisco, School of Medicine. They also interviewed SRC faculty advisors. Interviews focused on student roles in SRCs, SBP learning opportunities in SRCs, and comparisons of SBP experiences in SRCs with those in the formal preclerkship curriculum. The authors used thematic analysis techniques to code and synthesize data. RESULTS: Data from interviews with 8 volunteers, 14 coordinators, and 4 faculty suggested six major domains related to SBP learning opportunities in SRCs: interprofessional roles and collaboration; clinic organization; patient factors affecting access to care; awareness of the larger health care system and continuity of care; resource acquisition and allocation; and systems improvement. Coordinators, who managed SRCs, demonstrated greater depth of SBP understanding than volunteers, who provided patient care. Students and faculty agreed that SRCs provided students with SBP learning opportunities beyond those available in the formal curriculum. CONCLUSIONS: Preclerkship students' participation in SRCs provides opportunities for in-depth learning of SBP, particularly among students who take on leadership roles. SRCs may model ways to effectively introduce key components of SBP to early medical learners.


Assuntos
Educação Médica/métodos , Prática Clínica Baseada em Evidências , Instalações de Saúde , Estudantes de Medicina , Adulto , California , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino
18.
J Community Health ; 38(3): 471-9, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23161212

RESUMO

While student-run clinics are often important healthcare safety nets for underserved populations, their efficacy for improving patient health knowledge has not been thoroughly explored. From September 2011 to April 2012, we assessed patients' retention of hepatitis B virus (HBV) knowledge after receiving student-led education at two student-run HBV screening and vaccination clinics. Patient education was provided by trained first and second-year medical, nursing, and pharmacy students, aided by a script and interpreters. Patient knowledge of HBV was evaluated at three points: before education, after the initial visit, and at one-month follow-up. Student-led education produced improved knowledge of HBV transmission, prevention, and management, which was retained 1 month after education for 52 patients tracked through time. Mean scores on an HBV knowledge survey improved from 56.4 % (SD = 15.2 %) at baseline to 66.6 % (SD = 15.1 %) after education, and 68.3 % (SD = 15.2 %) after one month. There was a statistically significant difference between the first and second (paired T test, p < 0.001) and the first and third tests (paired T test, p < 0.001), but no difference between the second and third tests (paired T test, p = 0.45). Multivariate analysis demonstrated that retention was correlated with patient educational background but independent of patient age, gender, income, primary language and number of years lived in the United States. Our study suggests that trained health professional students can effectively impart health knowledge that is retained by patients for at least 1 month. These results warrant consideration of student-led educational sessions at SRCs as a promising community health education model.


Assuntos
Educação em Saúde/métodos , Conhecimentos, Atitudes e Prática em Saúde , Hepatite B/psicologia , Coleta de Dados , Emigrantes e Imigrantes/psicologia , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Hepatite B/prevenção & controle , Hepatite B/terapia , Humanos , Masculino , Pessoa de Meia-Idade , São Francisco , Fatores Socioeconômicos , Estudantes
19.
J Health Care Poor Underserved ; 23(3): 1058-72, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24212159

RESUMO

INTRODUCTION: Descriptive studies suggest student-run clinics (SRCs) positively affect preclinical students' sociocultural and interprofessional attitudes, but few studies use validated measures. METHODS: In a pre-post design, first-year medical, nursing, and pharmacy students who did and did not participate in SRCs completed demographic and open-ended questions, as well as two validated surveys, the Sociocultural Attitudes in Medicine Inventory (SAMI) and Readiness for Interprofessional Learning Scale (RIPLS), at the beginning and end of the year. RESULTS: With 68% (n=182/267) matched surveys we found no significant differences between groups over time (SAMI p=.53, RIPLS p≥.28 for each subcategory). However, of SRC participants, 99% reported commitment to the underserved and 57% reported improved interprofessional attitudes. DISCUSSION: Students participating in SRCs perceive positive benefits, but do not score differently from those who do not. The SRC experiences may not be frequent enough to affect these measures, particularly since our students were high-scoring upon entry.


Assuntos
Instituições de Assistência Ambulatorial , Atitude do Pessoal de Saúde , Relações Interprofissionais , Área Carente de Assistência Médica , Estudantes de Ciências da Saúde , Competência Cultural , Humanos , Estudos Prospectivos , Inquéritos e Questionários , Estados Unidos , Serviços Urbanos de Saúde
20.
J Proteome Res ; 10(1): 339-48, 2011 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-21105745

RESUMO

The mycobacterial cell wall component lipoarabinomannan (LAM) has been described as one of the key virulence factors of Mycobacterium tuberculosis. Modification of the terminal arabinan residues of this lipoglycan with mannose caps in M. tuberculosis or with phosphoinositol caps in Mycobacterium smegmatis results in distinct host immune responses. Given that M. tuberculosis typically persists in the phagosomal vacuole after being phagocytosed by macrophages, we performed a proteomic analysis of that organelle after treatment of macrophages with LAMs purified from the two mycobacterial species. The quantitative changes in phagosomal proteins suggested a distinct role for mannose-capped LAM in modulating protein trafficking pathways that contribute to the arrest of phagosome maturation. Enlightened by our proteomic data, we performed further experiments to show that only the LAM from M. tuberculosis inhibits accumulation of autophagic vacuoles in the macrophage, suggesting a new function for this virulence-associated lipid.


Assuntos
Autofagia/efeitos dos fármacos , Membranas Intracelulares/química , Lipopolissacarídeos/farmacologia , Macrófagos/metabolismo , Mycobacterium tuberculosis/química , Fagossomos/metabolismo , Animais , Antígenos de Bactérias/farmacologia , Immunoblotting , Marcação por Isótopo , Camundongos , Microscopia de Fluorescência , Fragmentos de Peptídeos/química , Fragmentos de Peptídeos/metabolismo , Fosfatidilinositóis/farmacologia , Transporte Proteico/efeitos dos fármacos , Proteômica/métodos , Reprodutibilidade dos Testes , Espectrometria de Massas em Tandem , Tripsina/metabolismo , Proteínas de Transporte Vesicular/metabolismo
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