Challenges and opportunities in cultivating medical students' competencies: Participatory action research from a hierarchical cultural setting.

BACKGROUNDS: Research concerning student-centered learning (SCL) recommends a comprehensive assessment of medical students' competencies including their personal and professional characters. Accordingly, nurturing future doctors should be in a continuous mentorship program. However, in a hierarchical culture, communication is one-way with limited feedback and reflection. We aimed to explore challenges and opportunities for SCL implementation in medical schools in this cultural setting necessary for a globally interdependent world. METHODS: Two cycles of participatory action research (PAR) were conducted, involving medical students and teachers in Indonesia. A national conference on SCL principles was conducted between the cycles, also the SCL modules were developed for each institution and feedback was shared. Twelve focus group discussions were conducted (before and after the module development), with 37 medical teachers and 48 medical students from 7 faculties of medicine across Indonesia at various levels accreditation. Following verbatim transcriptions, a thematic analysis was conducted. RESULTS AND DISCUSSIONS: In cycle 1 PAR, some challenges in implementing SCL were identified: lack of constructive feedback, overloaded content, summative-based assessment, hierarchical culture environment, and teachers' dilemma of committed time between patient-care and education. In cycle 2, several opportunities to approach the SCL were proposed: a faculty development program on mentorship, students' reflection guides and training, a more longitudinal assessment system, also a more supportive government policy on the human resources system. CONCLUSIONS: The main challenge of fostering student-centered learning revealed in this study was a teacher-centered learning tendency in the medical curriculum. The weighting towards summative assessment and the national educational policy drive the curriculum like a 'domino effect', away from the expected student-centered learning principles. However, using a participative method, students and teachers could identify opportunities and articulate their educational needs, i.e., a partnership-mentorship program, as a significant step toward student-centered learning in this cultural context.

Radiology resident education - Keys to successful workstation teaching.

Resident education is a complex process that requires many inputs from both the learner and the educator. As teaching faculty, many radiologists rely on two main methods to impart knowledge to their residents; namely didactic/case-based lectures and workstation teaching. The traditional lecture format is well known to both the learner and the educator, as this has been the primary platform that has been used almost universally. In addition, there are a multitude of excellent recorded and live lectures that faculty members can access from national society meetings that can be used as an example of how to give an effective well-organized lecture. Workstation teaching, on the other hand, is instead a more individualistic endeavor that is quite heterogeneous across institutions. In addition, there is very little in the literature that describes effective strategies that can be used to optimize the educational experience for the resident. This discussion will focus on pre-readout, readout, and post-readout strategies that educators can use at the workstation. Implementation of these techniques can be extremely helpful in accelerating resident progression through their training.

[Data analysis in rheumatology practices : Possibilities, limitations, and results]. / Datenanalysen in Rheumapraxen : Möglichkeiten, Grenzen und Ergebnisse.

Data analyses in rheumatology practices can be used as a feedback system in quality management. Implementation of a representative patient survey enables evaluation of one's own work and can be used for external presentation of the practice. Patient education and the structured use of specialist rheumatology assistants were evaluated by means of a survey. Systematic screening for depressive symptoms was carried out and enables a better understanding of patients and their "unmet needs". An analysis of the diseases and the patients in terms of physical function, disease activity, medication, and concomitant diseases is possible using structured patient documentation in a specialized documentation system. Within the RHADAR network (RheumaDatenRhePort G.b.R.), the proportion of rheumatoid arthritis patients treated with Janus kinase inhibitors was compared between different centers. Patients suitable for clinical trials can be filtered out of a structured documentation system.

Teaching pediatric behavior management in student dentists with constructive video feedback from faculty.

PURPOSE: The range of child behaviors encountered in real-life situations far exceeds that of any classroom-based simulated scenarios. For such reasons, clinical training with real-time clinical supervisor's feedback is optimal for learner-centricity. This study aimed to objectively evaluate the effect of video feedback on the student dentist's ability to manage behaviors in children. METHODS: Third-year dental student volunteers were randomly allocated to two groups: control and intervention. They were video recorded for three pediatric dental treatment sessions and received standard feedback for all sessions. Additionally, the intervention group received two constructive 1-on-1 feedback sessions after the first and second video sessions. Students' application of behavior management techniques for all recorded treatment sessions was scored with a study-specific objective scale (maximum score: 20; larger score indicating better performance) by two independent and blinded evaluators. A self-administered student questionnaire elicited subjective feedback on the intervention. RESULTS: There was a significant difference (p = 0.008) between behavior management scores when comparing all pre-intervention sessions (10.74 ± 3.55) and all post-intervention sessions (13.57 ± 2.96). The intervention significantly improved these techniques: 1. Providing specific feedback - positive reinforcement and descriptive praise (p = 0.006) and 2. Distraction - Using imagination with stories and singing (p = 0.035). The feedback sessions (4.29 ± 0.54) were perceived to be significantly (p = 0.032) more effective than having the students view the videos on their own (3.76 ± 0.87). CONCLUSION: Video feedback improved the behavior management scores of student dentists. The faculty feedback sessions were found by student dentists to improve confidence and the techniques for managing children.

[Debriefing in pediatric emergency care]. / Debriefing in der Kindernotfallversorgung: Grundlage für die Verbesserung der Patientenversorgung.

Communication errors and system problems negatively impact teamwork and shared decision-making and can cause patient harm. However, regular debriefings after critical events positively impact teamwork and patient outcome in pediatric emergency care. Team reflection promotes learning, helps teams to improve and to minimize errors from being repeated in the future. Nevertheless, debriefings in daily practice have not yet become a standard quality marker. Reasons include lack of time, lack of experienced debriefers and lack of support from the key stakeholders. Debriefings can take place at different timepoints with variable duration as needed. Due to the global pandemic, virtual debriefings or hybrid events with a mix of virtual and in-person participation are not only currently relevant but may perhaps also be of future relevance. Debriefings should focus on collaborative learning and future-oriented improvements. Not only life-threatening events but also potentially critical situations such as routine intubations warrant debriefings. Debriefing scripts promote a structured approach and allow even inexperienced moderators to navigate all relevant aspects. In addition to areas of challenge, debriefings should also explore and reinforce positive performance to facilitate learning from success. Debriefers should discuss not only obvious observable accomplishments, but also motivations behind key behaviors. This strategy promotes needs-based learning and focuses on solutions. Helpful strategies include specific questioning techniques, genuine interest and a positive safety culture.

Improving Student Feedback Quality: A Simple Model Using Peer Review and Feedback Rubrics.

Constructive feedback is an important aspect of medical education to help students improve performance in cognitive and clinical skills assessments. However, for students to appropriately act on feedback, they must recognize quality feedback and have the opportunity to practice giving, receiving, and acting on feedback. We incorporated feedback literacy into a case-based concept mapping small group-learning course. Student groups engaged in peer review of group-constructed concept maps and provided written peer feedback. Faculty also provided written feedback on group concept maps and used a simple rubric to assess the quality of peer feedback. Groups were provided feedback on a weekly basis providing an opportunity for timely improvement. Precourse and postcourse evaluations along with peer-review feedback assessment scores were used to show improvement in both group and individual student feedback quality. Feedback quality was compared to a control student cohort that engaged in the identical course without implementing peer review or feedback assessment. Student feedback quality was significantly improved with feedback training compared to the control cohort. Furthermore, our analysis shows that this skill transferred to the quality of student feedback on course evaluations. Feedback training using a simple rubric along with opportunities to act on feedback greatly enhanced student feedback quality.

A culture of caring: the essence of healthcare interprofessional collaboration.

Collaboration among healthcare professionals is essential in creating a synergy to provide efficient, safe, and high-quality patient care. Interprofessional collaborative practice (IPCP) has become a core measure in promoting healthcare practice. An understanding of the underlying mechanism for healthcare professionals to collaborate can provide strategies to foster IPCP. The purpose of the study was to investigate healthcare professionals' perspectives on ways to promote IPCP. This was a qualitative descriptive study. Thirty-six healthcare professionals from a university-affiliated hospital participated in the study. Data were collected via face-to-face in-depth interviews and analyzed using a thematic networks framework. The findings indicated that the underlying facilitator of IPCP was a culture of caring - human connections among interprofessional team members. The culture of caring could be fostered through five processes: building caring relationships, developing an ownership mentality, providing constructive feedback, applying the strengths-based practice, and acting as the first and last lines of defense. An Interprofessional Caring Model (ICM) was proposed in this study. Creating a caring culture is a dynamic process requiring all team members' efforts. The ICM can have significant clinical implications. It can be used as a framework to design and implement specific strategies to improve interprofessional collaboration.

Validation of a Spanish version of a 360° feedback tool for residents' performance: A pilot study.

Background: The 360° feedback tool emerges as one of the most effective techniques for the assessment of humanistic qualities and communication skills of medical trainees, providing effective feedback. A valid Spanish version of this tool has not yet been published. The aim of this study was to evaluate the validity, reliability and feasibility rates of the Mini-peer Assessment Tool (Mini-PAT), a 360° feedback instrument, translated into Spanish applied on a cardiology residency program. Methods: : We translated the Mini-PAT questionnaire into Spanish. The validation sample included all residents in our cardiology program (n = 19). Each resident was evaluated by 8 raters chosen by themselves, through a 4-point Likert scale. Validity was evaluated with factor analysis and reliability by analyzing internal consistency using the Cronbach's alpha coefficient. Feasibility was defined by a minimum of 80% of the raters responding the questionnaire. Results: The factor analysis clearly identified five item groupings, similar to the theoretical attributes predefined in the original questionnaire, providing evidence of the validity of the Spanish version. The Cronbach's alpha coefficient was 0.92, indicating high internal consistency of the items included. All the evaluators proposed completed the electronic form (152 surveys) demonstrating feasibility to implement. Discussion: This study provides evidence of reliability and validity of the Spanish version of the 360° feedback tool Mini-PAT performed in a cardiology residency program to assess global performance and humanistic qualities.

Does learning from mistakes have to be painful? Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common repetitive reporting errors and suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons.

BACKGROUND: The Royal College of Radiologists (RCR) and General Medical Council (GMC) encourage learning from mistakes. But negative feedback can be a demoralising process with adverse implications for staff morale, clinical engagement, team working and perhaps even patient outcomes. We first reviewed the literature regarding positive feedback and teamworking. We wanted to see if we could reconcile our guidance to review and learn from mistakes with evidence that positive interactions had a better effect on teamworking and outcomes than negative interactions. We then aimed to review and categorise the over 600 (mainly discrepancy) cases discussed in our educational cases meeting into educational 'themes'. Finally, we explored whether we could use these educational themes to deliver the same teaching points in a more positive way. METHODS AND RESULTS: The attendance records, programmes and educational cases from 30 consecutive bimonthly meetings between 2011 and 2017 were prospectively collated and retrospectively analysed. Six hundred and thirty-two cases were collated over the study period where 76% of the cases submitted were discrepancies, or perceived errors. Eight percent were 'good spots' where examples of good calls, excellent reporting, exemplary practice or subtle findings that were successfully reported. Eight percent were educational cases in which no mistake had been made. The remaining 7% included procedural complications or system errors. CONCLUSION: By analysing the pattern of discrepancies in a department and delivering the teaching in a less negative way, the 'lead' of clinical errors can be turned in to the 'gold' of useful educational tools. Interrogating the whole database periodically can enable a more constructive, wider view of the meeting itself, highlight recurrent deficiencies in practice, and point to where the need for continuing medical training is greatest. Three ways in which our department have utilised this material are outlined: the use of 'good spots', arrangement of targeted teaching and production of specialist educational material. These techniques can all contribute to a more positive learning experience with the emphasis on acknowledging and celebrating excellence (ACE).

Interprofessional communication in a socio-hierarchical culture: development of the TRI-O guide.

OBJECTIVES: Interprofessional education (IPE) and collaborative practice are essential for patient safety. Effective teamwork starting with partnership-based communications should be introduced early in the educational process. Many societies in the world hold socio-hierarchical culture with a wide power distance, which makes collaboration among health professionals challenging. Since an appropriate communication framework for this context is not yet available, this study filled that gap by developing a guide for interprofessional communication, which is best suited to the socio-hierarchical and socio-cultural contexts. MATERIALS AND METHODS: The draft of the guide was constructed based on previous studies of communication in health care in a socio-hierarchical context, referred to international IPE literature, and refined by focus group discussions among various health professionals. Nominal group technique, also comments from national and international experts of communication skills in health care, was used to validate the guide. A pilot study with a pre-posttest design was conducted with 53 first- and 107 fourth-year undergraduate medical, nursing, and health nutrition students. RESULTS: We developed the "TRI-O" guide of interprofessional communication skills, emphasizing "open for collaboration, open for information, open for discussion", and found that the application of the guide during training was feasible and positively influenced students' perceptions. CONCLUSION: The findings suggest that the TRI-O guide is beneficial to help students initiate partnership-based communication and mutual collaboration among health professionals in the socio-hierarchical and socio-cultural context.

Undergraduate Medical Students' Perceptions on Feedback-Seeking Behaviour.

BACKGROUND: The concept of feedback-seeking behaviour has been widely studied, but there is still a lack of understanding of this phenomenon, specifically in an Indonesian medical education setting. The aim of this research was to investigate medical students' feedback-seeking behaviour in depth in one Indonesian medical school. METHODS: A qualitative method was employed to explore the feedback-seeking behaviour of undergraduate medical students in the Faculty of Medicine at Universitas Lampung. Focus group discussions (FGDs) were conducted with four student groups and each group consisted of 7-10 students from the years 2012, 2013 and 2014. Data triangulation was carried out through FGDs with teaching staff, and an interview with the Head of the Medical Education Unit. RESULTS: Study findings indicated that the motivation of students to seek feedback was underlain by the desire to obtain useful information and to control the impressions of others. Students will tend to seek feedback from someone to whom they have either a close relationship or whose credibility they value. The most common obstacle for students to seek feedback is the reluctance and fearfulness of receiving negative comments. CONCLUSIONS: Through the identification of factors promoting and inhibiting feedback-seeking behaviour, medical education institutions are enabled to implement the appropriate and necessary measures to create a supportive feedback atmosphere in the learning process.

Undergraduate Medical Students’ Perceptions on Feedback-Seeking Behaviour

Background: The concept of feedback-seeking behaviour has been widely studied, but there is still a lack of understanding of this phenomenon, specifically in an Indonesian medical education setting. The aim of this research was to investigate medical students’ feedback-seeking behaviour in depth in one Indonesian medical school. Methods: A qualitative method was employed to explore the feedback-seeking behaviour of undergraduate medical students in the Faculty of Medicine at Universitas Lampung. Focus group discussions (FGDs) were conducted with four student groups and each group consisted of 7–10 students from the years 2012, 2013 and 2014. Data triangulation was carried out through FGDs with teaching staff, and an interview with the Head of the Medical Education Unit. Results: Study findings indicated that the motivation of students to seek feedback was underlain by the desire to obtain useful information and to control the impressions of others. Students will tend to seek feedback from someone to whom they have either a close relationship or whose credibility they value. The most common obstacle for students to seek feedback is the reluctance and fearfulness of receiving negative comments. Conclusions: Through the identification of factors promoting and inhibiting feedbackseeking behaviour, medical education institutions are enabled to implement the appropriate and necessary measures to create a supportive feedback atmosphere in the learning process.

Feedback in a clinical setting: A way forward to enhance student's learning through constructive feedback.

Feedback is considered as a dynamic process in which information about the observed performance is used to promote the desirable behaviour and correct the negative ones. The importance of feedback is widely acknowledged, but still there seems to be inconsistency in the amount, type and timing of feedback received from the clinical faculty. No significant effort has been put forward from the educator end to empower the learners with the skills of receiving and using the feedback effectively. Some institutions conduct faculty development workshops and courses to facilitate the clinicians on how best to deliver constructive feedback to the learners. Despite of all these struggles learners are not fully satisfied with the quality of feedback received from their busy clinicians. The aim of this paper is to highlight what actually feedback is, type and structure of feedback, the essential components of a constructive feedback, benefits of providing feedback, barriers affecting the provision of timely feedback and different models used for providing feedback. The ultimate purpose of this paper is to provide sufficient information to the clinical directors that there is a need to establish a robust system for giving feedback to learners and to inform all the clinical educators with the skills required to provide constructive feedback to their learners. For the literature review, we had used the key words glossary as: Feedback, constructive feedback, barriers to feedback, principles of constructive feedback, Models of feedback, reflection, self-assessment and clinical practice etc. The data bases for the search include: Cardiff University library catalogue, Pub Med, Google Scholar, Web of Knowledge and Science direct.

La retroalimentación constructiva en el desarrollo de habilidades comunicativas escritas e investigativas en dos generaciones de alumnos de medicina en Yucatán, México / Constructive feedback in the development of written and research communicational skills in two generations of medical students in Yucatan, Mexico

Antecedentes. La generación de competencias para la investigación en medicina es fundamental para que los médicos apliquen lashabilidades científicas en su quehacer diario; los programas académicos que incluyen la formación de habilidades investigativasrequieren a su vez habilidades para la comunicación escrita en los alumnos. La retroalimentación constructiva es un medio comúnmenteempleado en medicina, por el cual el docente acompaña al alumno, dándole a conocer sus fortalezas, debilidades y oportunidadespara un mejor desempeño, mientras asegura una evaluación justa. A pesar de ello, su aplicación más difundida es en la práctica clínicay no en el aprendizaje de la redacción y comunicación científica. Objetivo. Evaluar el impacto de la retroalimentación constructiva enel desempeño de los estudiantes en sus propuestas de protocolos clínicos y epidemiológicos considerando aspectos de redacción ymetodológicos. Diseño. Estudio analítico, prospectivo. Lugar. Universidad Marista de Mérida, Yucatán, México. Participantes. Alumnosregulares que cursaron la materia Métodos Clínicos y Epidemiológicos de la carrera de Médico Cirujano durante los ciclos escolares2014-2015 y 2015-2016. Intervención. Se evaluaron los puntajes obtenidos en el protocolo de investigación antes y después de laretroalimentación constructiva. Resultados. La media de la puntuación inicial de los protocolos fue 8,3 ± 0,8 y la media posterior a laretroalimentación constructiva fue 9,4 ± 0,9; el incremento de las puntuaciones en promedio fue de 1,1 ± 0,1 con un valor de t=7,70p=0,000. Las habilidades para la comunicación escrita que mejoraron los alumnos fueron fundamentalmente: 1. El manejo del tema,2. La organización del texto, 3. Empleo del lenguaje escrito, redacción, y 4. Fuentes de información; los alumnos presentan todaslas ideas no propias en su escrito con las citas a la fuente de donde fueron extraídas...

Background: Research and written communication skills are essential in undergraduate medical education, because medical doctors are often involved in research, and written communication is part of a medical doctor's everyday routine. Academic medical programs that include training in clinical or epidemiological research require written communication aptitudes. Constructive feedback is a review technique commonly employed in medical education that involves the professor's close surveillance of the student’s performance and a clear communication to respectfully explain to students their strengths, weaknesses and opportunities of improvement, while ensuring a fair evaluation. Even though constructive feedback is common in clinical practice, it is rarely used in undergraduate medical training in scientific writing. Objective: To evaluate the impact of constructive feedback on the academic performance of students in their clinical or epidemiological research protocol proposals, involving written and methodological aspects. Design: Analytical, prospective study. Setting: Universidad Marista de M‚rida, Yucat n, M‚xico. Participants: Students in their fourth year of medical education. Intervention: The quantitative evaluations obtained in the research protocol proposals before and after the constructive feedback were compared in 103 students in their fourth year of medical education who were attending the Clinical and Epidemiological Research Methods course during 2014-2015 and 2015-2016 school years. Results: The mean of the initial score was 8.3 ñ 0.8, and the mean post constructive feedback was 9.4 ñ 0.9; the average score increase was 1.1 ñ0.10 with t=7.70 value, p=0.000. Students improved the following communication skills: 1. Theme presentation and review, 2. Organization of a scientific manuscript, 3. Use of written language, and 4. Use of information sources...

Feedback in the nonshifting context of the midwifery clinical education in Indonesia: A mixed methods study.

BACKGROUND: Clinical education in some countries applies a hospital-based learning approach where each student rotates to one division to another division (call of shifting). However, for clinical midwifery education in Indonesia each student remains in a community midwifery clinic (call of nonshifting). Because of the differences in the shifting system used, the question of "How is feedback in the nonshifting context of the clinical midwifery education being given?" needs to be explored. MATERIALS AND METHODS: This was a mixed methods study and was carried out in a School of Midwifery in Indonesia during 2014 and 2015. We explored the supervisors' and students' perception on the feedback delivery. Students' perceptions were collected through focus group discussions whereas supervisors' perceptions were recorded through interviews. The quality of feedback was observed using a checklist. Qualitative data were analyzed using Atlas Ti and quantitative data were analyzed using a descriptive statistic method. RESULTS: From the qualitative data, students and supervisors perceived their feedback as "more intensive." They reported authenticity in the monitoring and feedback from the day-to-day delivery of patient care with their supervisors. Students and supervisors also described their feedback as "more integrated." The feedback process stimulated students to value history taking, physical examination, and midwifery care. On the other hand, quantitative data from observations presented that "intensive and integrated feedback" were not supported by the quality of the feedback based on literature of the theory of facilitating learning (the mean was 4.67 on a scale of 0-9). CONCLUSIONS: The nonshifting clinical midwifery education can be a better alternative for facilitating the process of providing integrated and intensive feedback. To improve the quality of the feedback, training on providing feedback in a nonshifting context is fundamental in Indonesia.

Mini-CEX: una herramienta que integra la observación directa y la devolución constructiva para la evaluación del desempeño profesional / Mini-CEX: A Method Integrating Direct Observation and Constructive Feedback for Assessing Professional Performance / Mini-CEX: A Method Integrating Direct Observation and Constructive Feedback for Assessing Professional Performance

El mini-CEX (mini clinical evaluation exercise) es un instrumento de evaluación del desempeño profesional a través de la observación directa del residente mientras participa de un encuentro con un paciente, la valoración de una serie de habilidades y destrezas clínicas con posterior provisión de feedback o devolución en su ámbito de trabajo. Se centra en una serie de habilidades que el residente debe demostrar durante el encuentro con un paciente y requiere que el docente documente ese desempeño en seis competencias. Es fácil de aplicar por los docentes porque se integra bien a la rutina del día a día en los diferentes escenarios clínicos. El tiempo estimado de esta interacción no debe superar los 20 minutos y debe repetirse al menos 8 veces al año con cada residente por diferentes docentes. Es de vital importancia que los docentes definan de antemano qué competencias se van a evaluar y cuáles son los estándares de desempeño mínimo que deberán alcanzar los residentes. La confección de una base de datos con la información de los formularios completados nos permitirá monitorizar el proceso de evaluación y efectuar las medidas correctivas pertinentes.

The mini-CEX (mini clinical evaluation exercise) is a tool for the assessment of professional performance of residents through direct observation of resident-patient encounter, evaluating clinical skills and providing subsequent feedback in the work setting. The exam focuses on the evaluation of resident's skills during resident-patient encounter. The evaluator must document resident's performance in six areas of competence. The exam is easy to apply as it fits in real life settings in the different clinical scenarios. The evaluation should not take more than 20 minutes and each resident should have 8 mini-CEX per year of training with different faculties. Faculties should previously define the areas of competence to evaluate and the minimum performance standards residents should reach. All the completed forms should be used to construct a database in order to monitor the evaluation process and make the necessary corrections.