Experiential Learning and Mentorship in Global Health Leadership Programs: Capturing Lessons from Across the Globe.

Objectives: The changing global landscape of disease and public health crises, such as the current COVID-19 pandemic, call for a new generation of global health leaders. As global health leadership programs evolve, many have incorporated experiential learning and mentoring (ELM) components into their structure. However, there has been incomplete consideration on how ELM activities are deployed, what challenges they face and how programs adapt to meet those challenges. This paper builds on the co-authors' experiences as trainees, trainers, organizers and evaluators of six global health leadership programs to reflect on lessons learned regarding ELM. We also consider ethics, technology, gender, age and framing that influence how ELM activities are developed and implemented. Findings: Despite the diverse origins and funding of these programs, all six are focused on training participants from low- and middle-income countries drawing on a diversity of professions. Each program uses mixed didactic approaches, practice-based placements, competency and skills-driven curricula, and mentorship via various modalities. Main metrics for success include development of trainee networks, acquisition of skills and formation of relationships; programs that included research training had specific research metrics as well. Common challenges the programs face include ensuring clarity of expectations of all participants and mentors; maintaining connection among trainees; meeting the needs of trainee cohorts with different skill sets and starting points; and ensuring trainee cohorts capture age, gender and other forms of diversity. Conclusions: ELM activities for global health leadership are proving even more critical now as the importance of effective individual leaders in responding to crises becomes evident. Future efforts for ELM in global health leadership should emphasize local adaptation and sustainability. Practice-based learning and established mentoring relationships provide the building blocks for competent leaders to navigate complex dynamics with the flexibility and conscientiousness needed to improve the health of global populations. Key Takeaways: Experiential learning and mentorship activities within global health leadership programs provide the hands-on practice and support that the next generation of global health leaders need to address the health challenges of our times.Six global health leadership programs with experiential learning and mentorship components are showcased to highlight differences and similarities in their approaches and capture a broad picture of achievements that can help inform future programs.Emphasis on inter-professional training, mixed-learning approaches and mentorship modalities were common across programs. Both individual capacity building and development of trainees' professional networks were seen as critical, reflecting the value of inter-personal connections for long-term leadership success.During program design, future programs should recognize the "frame" within which the program will be incorporated and intentionally address diversity-in all its forms-during recruitment as well as consider North-South ethics, leadership roles, hierarchies and transition plans.

Transforming Disruption Into Innovation: A Partnership Between the COVID-19 Medical Student Response Team and the University of British Columbia.

The COVID-19 pandemic caused substantial disruptions in medical education. The University of British Columbia (UBC) MD Undergraduate Program (MDUP) is the sixth-largest medical school in North America. MDUP students and faculty developed a joint response to these disruptions to address the curriculum and public health challenges that the pandemic posed. After clinical activities were suspended in March 2020, third- and fourth-year MDUP students formed a COVID-19 Medical Student Response Team (MSRT) to support frontline physicians, public health agencies, and community members affected by the pandemic. A nimble organizational structure was developed across 4 UBC campuses to ensure a rapid response to meet physician and community needs. Support from the faculty ensured the activities were safe for the public, patients, and students and facilitated the provision of curricular credit for volunteer activities meeting academic criteria. As of June 19, 2020, more than 700 medical students had signed up to participate in 68 projects. The majority of students participated in projects supporting the health care system, including performing contact tracing, staffing public COVID-19 call centers, distributing personal protective equipment, and creating educational multimedia products. Many initiatives have been integrated into the MDUP curriculum as scholarly activities or paraclinical electives for which academic credit is awarded. This was made possible by the inherent flexibility of the MDUP curriculum and a strong existing partnership between students and faculty. Through this process, medical students were able to develop fundamental leadership, advocacy, communication, and collaboration skills, essential competencies for graduating physicians. In developing a transparent, accountable, and inclusive organization, students were able to effectively meet community needs during a crisis and create a sustainable and democratic structure capable of responding to future emergencies. Open dialogue between the MSRT and the faculty allowed for collaborative problem solving and the opportunity to transform disruption into academic innovation.

Implementation of a Standardized Neonatal Intubation Training Package.

OBJECTIVE: To assess the first attempt neonatal intubation success rates of pediatric trainees following the implementation of an evidence-based training package. STUDY DESIGN: Data collection was undertaken from February, 1 2017, to January 31, 2018, to ascertain baseline preimplementation intubation success rates. An intubation training package, which included the use of videolaryngoscopy, preprocedure pause, and standardized instruction during the procedure, was introduced. Data on all subsequent intubations were collected prospectively from May 1, 2018, to April 30, 2020. RESULTS: Preimplementation baseline data over a 1-year period demonstrated overall first attempt intubation success rate of junior trainees to be 37% (33/89). After implementation of the training package, 290 intubations were analyzed over a 2-year period. The overall success rate was 67% (194/290); 61% (117/192) for junior trainees and 79% (77/98) for senior clinicians. Three or more attempts were required for 13% of intubations (38/290). During the study period, the overall number of intubations being carried out decreased. Intubations with the videolaryngoscope had higher success rates for all tiers of clinician, most marked in the junior tiers. CONCLUSIONS: The introduction of a standardized intubation training package, along with videolaryngoscopy, improved trainee intubation success rates.

Restructuring the clinical curriculum at University Medical Center Göttingen: effects of distance teaching on students' satisfaction and learning outcome.

Introduction: In summer term 2020, the clinical phase of the undergraduate medical curriculum at University Medical Center Göttingen was restructured since distance teaching had to be used predominantly due to contact restrictions during the COVID-19 pandemic. This paper investigates the impact of restructuring the clinical curriculum on medical students' satisfaction and learning outcomes. Methods: In each cohort, the 13-week curriculum was divided into two parts: During the first 9 weeks, factual knowledge was imparted using distance teaching by means of a modified inverted classroom approach. This was followed by a 4-week period of adapted classroom teaching involving both real and virtual patients in order to train students' practical skills. The evaluation of the 21 clinical modules comprised students' satisfaction with distance teaching as well as students' learning outcome. The latter was assessed by means of comparative self-assessment (CSA) gain and the results of the module exams, respectively. Data of summer term 2020 (= distance teaching, DT) were compared with respective data of winter term 2019/20 (= classroom teaching, CT) and analysed for differences and correlations. Results: Response rates of evaluations were 51.3% in CT and 19.3% in DT. There was no significant difference between mean scores in module exams in CT and DT, respectively. However, CSA gain was significantly lower in DT (p=0.047) compared with CT. Further analyses revealed that CSA gain depended on the time point of data collection: CSA gain was lower the more time had passed since the end of a specific module. Moreover, we found positive correlations between CSA gain and students' satisfaction with various aspects of distance teaching, particularly with "communication between teachers and students" (rho=0.674; p=0.002). Discussion and conclusions: Although some limitations and confounding factors have to be taken into account (such as evaluation response rates, assessment time points, and proportion of familiar items in module exams), the following recommendations can be derived from our findings: A valid assessment of students' learning outcome by means of exam results requires that as few exam items as possible are familiar to the students. CSA gain seems to be valid if assessment time points are standardised and not contaminated by students' learning activities for other modules. Good communication between teachers and students may contribute to increase students' satisfaction with distance teaching.

The use of the online Inverted Classroom Model for digital teaching with gamification in medical studies.

Introduction: In 2014, a newly designed, case-based seminar was successfully implemented in the subjects of health systems, health economics and public health care (GGG). The seminar "The Lonely Patient" is based on a real patient case and deals with the German health care system from the perspective of a patient. In order to create more space for discussion and exchange among students, the seminar was redesigned on the basis of the Inverted Classroom Method (ICM). Project description: Due to the COVID-19 pandemic, new, purely digital teaching formats had to be developed quickly in the sense of Emergency Remote Teaching. Therefore, the Inverted Classroom concept of the seminar was transformed into an online ICM. In order to promote active learning based on the ICAP model (Interactive, Constructive, Active, Passive), the online face-to-face part was designed as a synchronous interactive learner-centered course using the gamified audience response system Kahoot! Results: Evaluation results to date and feedback rounds with students indicate that the online ICM-version of the seminar leads to at least as good evaluation results as the previous face-to-face course. In particular, the students positively emphasize the use of Kahoot! as an activating digital medium. Discussion: Through the use of the ICM and the gamified audience response system Kahoot!, students could be activated in meaningful ways. The resulting discussions about the patient case and teaching content of the quiz questions in the synchronous online course could be implemented just as well as in the classroom-based course of previous semesters. Conclusion: The application of the online ICM, along with the consideration of the ICAP Model, has led to the successful implementation of a digital course within the context of the increased difficulty surrounding the emergency remote teaching. Additionally, students' learning success has remained at a similar level as during traditional classroom-based courses of previous semesters.

Learning From What We Do, and Doing What We Learn: A Learning Health Care System in Action.

Different models of learning health systems are emerging. At Vanderbilt University Medical Center, the Learning Health Care System (LHS) Platform was established with the goal of creating generalizable knowledge. This differentiates the LHS Platform from other efforts that have adopted a quality improvement paradigm. By supporting pragmatic trials at the intersection of research, operations, and clinical care, the LHS Platform was designed to yield evidence for advancing content and processes of care through carefully designed, rigorous study. The LHS Platform provides the necessary infrastructure and governance to leverage translational, transdisciplinary team science to inform clinical and operational decision making across the health system. The process transforms a clinical or operational question into a research question amenable to a pragmatic trial. Scientific, technical, procedural, and human infrastructure is maintained for the design and execution of individual LHS projects. This includes experienced pragmatic trialists, project management, data science inclusive of biostatistics and clinical informatics, and regulatory support. Careful attention is paid to stakeholder engagement, including health care providers and the community. Capturing lessons from each new study, the LHS Platform continues to mature with plans to integrate implementation science and to complement clinical and process outcomes with cost and value considerations. The Vanderbilt University Medical Center LHS Platform is now a pillar of the health care system and leads the evolving culture of learning from what we do and doing what we learn.

Embedding Learning in a Learning Health Care System to Improve Clinical Practice.

PROBLEM: In an ideal learning health care system (LHS), clinicians learn from what they do and do what they learn, closing the evidence-to-practice gap. In operationalizing an LHS, great strides have been made in knowledge generation. Yet, considerable challenges remain to the broad uptake of identified best practices. To bridge the gap from generating actionable knowledge to applying that knowledge in clinical practice, and ultimately to improving outcomes, new information must be disseminated to and implemented by frontline clinicians. To date, the dissemination of this knowledge through traditional avenues has not achieved meaningful practice change quickly. APPROACH: Vanderbilt University Medical Center (VUMC) developed QuizTime, a smartphone application learning platform, to provide a mechanism for embedding workplace-based clinician learning in the LHS. QuizTime leverages spaced education and retrieval-based practice to facilitate practice change. Beginning in January 2020, clinician-researchers and educators at VUMC designed a randomized, controlled trial to test whether the QuizTime learning system influenced clinician behavior in the context of recent evidence supporting the use of balanced crystalloids rather than saline for intravenous fluid management and new regulations around opioid prescribing. OUTCOMES: Whether spaced education and retrieval-based practice influence clinician behavior and patient outcomes at the VUMC system level will be tested using the data currently being collected. NEXT STEPS: These findings will inform future directions for developing and deploying learning approaches at scale in an LHS, with the goal of closing the evidence-to-practice gap.

Using medical reality television as a technology-enhanced learning strategy to provide authentic patient care experiences during clinical placements: a case study research investigation.

BACKGROUND: Over the last decade, the use of technology-enhanced learning (TEL) has rapidly expanded and diversified. Since the COVID-19 pandemic, there is a growing demand for distance and online learning strategies to support and even replace learning experiences previously afforded by clinical placements and clerkships. An intriguing but under-researched modality is the use of medical reality television to provide authentic experiences of patient care. This strategy does not feature in published medical educational literature, though promising research is emerging from other disciplines. METHODOLOGY: A programme of learning using medical reality television clips to facilitate case-based learning was developed according to the principles of 'anchored instruction', a technology-based educational theory. Clips were taken from the UK television show '24 hours in A&E'. Medical students' learning experiences were investigated using a qualitative approach addressing the following research questions: - What is the perceived emotional experience of medical students when watching reality television in an educational context? - How do medical students relate their experience of watching reality television in a formal educational setting to their perceived learning needs in the clinical environment? A case study research methodology was adopted within the interpretivist paradigm. Data were triangulated from semi-structured interviews with students and non-participant observation of the teaching session. Field notes and transcripts were analysed through an inductive thematic analysis. RESULTS: In response to the medical reality television, a diverse range of emotions were expressed including: excitement, amusement, concern, nervousness, sadness and joy. Students identified gaps in their clinical knowledge such as interpreting results, practical aspects of prescribing and end of life care. Key themes were increased student engagement and a promotion of holistic care practices. DISCUSSION: Students perceived reality television as a highly realistic and relatable medium and an enjoyable, memorable way to contextualise learning from the classroom to real life, a finding mirrored in previous studies in other fields. The high degree of emotion expressed may explain the improved subjective memorability of the cases. CONCLUSION: Medical reality television offers a unique means of engaging students by providing authentic experiences of patient care and should be valued alongside other technology-enhanced learning strategies.

Resuscitating the Socratic Method: Student and Faculty Perspectives on Posing Probing Questions During Clinical Teaching.

PURPOSE: Teaching by way of asking questions is a time-honored practice that has taken on the negative connotation of "pimping" among medical students and has made some faculty hesitant to ask students questions during clerkship rotations. Yet, quantitative studies exploring student perspectives on this practice are limited. This study aimed to solicit student and faculty views and investigate faculty perceptions of students' preferences. METHOD: Students who completed their internal medicine clerkship during the 2017-2018 academic year (n = 165) and were from the 2020 graduating class and their supervising faculty (n = 144) at the University of Michigan Medical School were asked to complete a Likert response survey in April 2019. The survey solicited perspectives on questions probing medical knowledge posed to students by faculty. Surveys were constructed using an iterative process, and data were analyzed using t tests and linear regressions. RESULTS: A total of 140 (85%) students and 112 (78%) faculty participated. Of those, 125 (89%) students and 109 (97%) faculty agreed that probing questions are valuable for student education, but only 73 (65%) faculty perceived that students agreed with this statement (P < .001). In addition, 115 (82%) students preferred to be asked too many questions than none at all. Fifty-five (39%) students agreed that they feel humiliated when they answer a question incorrectly. However, only 7 (5%) students agreed that faculty ask questions to humiliate them, and only 20 (14%) preferred that faculty stop asking questions if they answer a question incorrectly. CONCLUSIONS: Students valued probing questions more than faculty perceived, which argues against a withdrawal from the Socratic teaching method in the clinical arena. The students' experience of humiliation when answering incorrectly requires further study and perhaps can be tempered by more explicit framing of the role of the questioning process.

Strategies for Managing Pharmacy Experiential Education During COVID-19.

In recent months, the coronavirus pandemic has significantly affected almost every industry in the United States, including health care and higher education. Faculty and students at colleges and schools of pharmacy nationwide have needed to quickly adapt as the delivery of curricula has shifted to primarily online format. Additionally, experiential rotations have been significantly affected as practice settings such as hospitals and outpatient clinics have limited students' interactions with patients or stopped allowing students on-site altogether. Our commentary will explore strategies that have been employed by experiential education coordinators and pharmacy preceptors from various settings to navigate experiential education during these difficult times while ensuring students successfully meet requirements for graduation. These will include descriptions of transitioning advanced pharmacy practice experiences (APPEs) to virtual format, how to safely involve students in the care of COVID-19 patients, and managing scheduling issues.

Improving pediatric problem-based learning sessions in undergraduate and graduate medical education.

PURPOSE OF REVIEW: Problem-based learning (PBL) sessions have become common alternatives to traditional didactic-style sessions in medical education, including within pediatric education. The creation and execution of PBL sessions, however, can vary among institutions and even between educators at a given institution. Coupling the personal experiences of a recently-graduated medical student with that of a knowledgeable medical educator, the authors sought to analyze two PBL session experiences of the medical student during her second year with the goal of pinpointing specific elements that add value for both learners and facilitators. RECENT FINDINGS: Through this analysis, the authors propose enhancements to PBL sessions that may make them more optimal for developing knowledge in pediatric medicine. These include utilizing an interactive video of the clinical problem to more uniformly assess the learner's knowledge gaps, supporting the creation and evolution of peer-to-peer learning communities, and helping to educate facilitators in how to guide dialogue in this type of educational setting. SUMMARY: The PBL enhancements identified by the authors provide educators with innovative suggestions to better engage pediatric trainees in building social capital, acquiring knowledge, and helping learners retain that knowledge beyond their assessments.

Retos para la implementación del aprendizaje basado en problemas en facultades de medicina en América Latina / No disponible

No disponible

Practical and Ethical Solutions for Remote Applied Learning Experiences in Global Health.

Global health trainees rely on immersive experiences to apply their classroom knowledge in real-world settings. However, during the COVID-19 pandemic travel has come to a halt and short-term experiences are no longer available in their current form. As with didactic material, global health programs have an opportunity to innovate the delivery of applied learning, providing trainees with robust, mentored experiences that promote the acquisition of core global health competencies. We provide a series of practical solutions for remote applied learning including case-based learning, pathfinder pedagogy, virtual reality simulations, and twinning. We further describe the role of these approaches in addressing common criticisms of short-term experiences and their potential for creating new win-win dynamics between institutions and trainees.

Does Dosing of Pediatric Experiential Learning Impact the Development of Clinical Reasoning, Self-Efficacy, and Critical Thinking in DPT Students?

AIMS: The purpose of this study was to explore the changes in clinical reasoning, self-efficacy, and critical thinking of a group of Doctor of Physical (DPT) students who completed a high and low dose of pediatric experiential learning (EL) as a component of their semester-long pediatric course. METHODS: A convenience sample of students at two DPT programs in the United States were recruited. A pre-test post-test comparison group design was used to examine the change in students' clinical reasoning, self-efficacy, and critical thinking following completion of a pediatric course that contained a high or low dose of EL. Students completed the Self-Assessment of Clinical Reflection and Reasoning, Physical Therapy Self-Efficacy Scale, and Health Science Reasoning Test during the first and last weeks of the semester. Students in the high-dose group reported a significant increase (p=0.000) over time in self-perceived clinical reasoning and self-efficacy. Overall critical thinking abilities significantly improved (p=0.044) over time in both groups. CONCLUSION: A high dose of pediatric EL seems to aid students in the development of self-perceived clinical reasoning and self-efficacy. Providing students with EL opportunities prior to pediatric rotations may help to bolster these important skills, leading to improved clinical performance.

Connecting Classrooms, Clinicians, and Community Clinics Through Technology (C4Tech) for Active and Collaborative Learning.

PURPOSE: This pilot study investigated the level of cognition that physician assistant (PA) students achieved through adoption of an innovative blended learning model that connects the classroom, clinicians, and community clinics through electronic-learning (e-learning) technologies (C4Tech) used in a PA course. This education intervention aimed to facilitate authentic learning collaborations between PA students and practicing clinicians that would result in higher-order cognition related to the manifestations of social determinants of health and health disparities. METHODS: A case study approach was adopted to assess levels of cognition and changes in those levels resulting from application of an innovative blended learning model. Content analysis using Bloom's taxonomy of cognitive domains facilitated determination levels of cognition and changes in those levels. The sample of 8 groups comprised 70 PA students and 8 clinical instructors from community clinics with underrepresented patient populations. RESULTS: Analysis of 2 course assignments revealed that application of the C4Tech model yields high levels of cognition. By the course's end, all 8 groups achieved at least the "evaluate" level of cognition and half of the groups achieved the highest level of cognition, the "create" level. A wide variation in the level of cognition was demonstrated between the first and second assignments in each group and among groups. CONCLUSION: Our findings suggest that e-learning technologies can be effective in blending classrooms and work environments for authentic and collaborative learning. Adoption of the C4Tech model yielded higher-order cognition related to course content.

Interactive pedagogical tools could be helpful for medical education continuity during COVID-19 outbreak.

Training and education are essential for medical students. During the COVID-19 outbreak, numerous schools and universities have had to close. Ensuring pedagogical continuity requires alternatives to the traditional classroom, especially in medical education. Usual distance learning tools such as videos and downloadable handouts are not sufficient to promote efficient teaching. Distance learning requires self-motivation and does not give you direct access to your instructor. Some students fear the loss of human contact with an instructor - like asking questions during and after class - which promotes learning, understanding and communication. Moreover, classical distance learning methods do not offer immediate feedback that can help students in their understanding of the lecture. In this context, interactive pedagogic tools (IPT) could be useful for medical education continuity and for maintaining human contact necessary in pedagogy. We briefly evaluated interactive pedagogic tool compared to traditionnal distancial tools on medical students. This study showed the importance to have direct contact with a teacher and feedback during a lecture and to not exclusively perform distance learning without direct interaction and feedback. Hence, in the present context, we encourage teacher to use this type of tools to maintain direct interaction with students - which is essential in pedagogy - and ensure a qualitative pedagogical continuity.

Experiential learning of overnight home care by medical trainees for professional development: an exploratory study.

OBJECTIVES: In an ageing society, community-based medical education in a home care setting needs to be developed. Drawing on Kolb's experiential learning theory, this study aimed to explore the learning processes in overnight home care by medical trainees in terms of their understanding of terminally ill patients and their conceptualization of themselves as future physicians. METHODS: An overnight home care program in which a trainee had to take care of terminally ill patients on his/her own under the supervision of a healthcare team was conducted. Nineteen trainees, including eight medical students and 11 residents, participated in this study. Text data of reflective reports written after the overnight care were collected and thematically analyzed. RESULTS: The trainees' learning experiences in the program were categorized into four stages: predeparture, concrete experience, reflective observation and abstract conceptualization. Although they had mixed feelings, including anxiety, fear and expectations, at the predeparture stage, they could be actively involved in providing medical care and daily life support and in taking care of dying patients at the patients' homes overnight. By reflecting on their experiences, they gained a sense of achievement and identified the aspects upon which they should improve as future physicians. Subsequently, based on their reflective observation, they conceptualized their approaches to home care and the roles/responsibilities of physicians as healers, which led to professional identity formation. CONCLUSIONS: Overnight home care by medical trainees has the potential as an educational strategy to promote their realistic understanding of home care and facilitate professional identity formation.

The benefits and challenges of a rural community-based work-ready placement program for allied health students.

INTRODUCTION: Rural and remote Australia has a shortage of allied health clinicians. The provision of quality rural placement experiences for allied health students has been a significant strategy to address these health workforce shortages. Service learning rural placements are providing allied health services in small rural towns where previously allied health services were limited or did not exist. Published literature has little detailed description of the origin or nature of particular placement programs. METHODS: An increase in Commonwealth funding for rural allied health clinical placements led to the development of an innovative service learning placement model in northern New South Wales, the Rural Community-Based Work-Ready Placement Program. During this placement, students were paired for 4-10 full-time weeks in a preschool, school or aged care facility. The program's fundamental properties included cultural and social equity education, providing continuous service throughout the year, and quality improvement initiatives in placement sites. The program was underpinned by an interdisciplinary approach that included interdisciplinary placements, interdisciplinary supervision and a structured interdisciplinary education program. RESULTS: The program required investment in stakeholder engagement and in the alignment of universities' requirements for student learning outcomes and the sites' specific needs. Clinical supervisors had to adapt to supervising students from various disciplines and universities across several sites, towns and services. The program provided students with opportunities to work autonomously, problem-solve and to initiate and implement quality improvement projects at each site. CONCLUSION: Careful selection of students, adequate preparation and management of students' expectations were important contributors to the success of the program. Providing a continuous service is an ongoing logistical challenge.

Practice-based learning: an appropriate means to acquire the attitude and skills for evidence-based medicine.

OBJECTIVES:   To evaluate a practice-based, self-directed EBM-course in an undergraduate medical curriculum in terms of EBM attitude and motivation beliefs. METHODS: This study was conducted in a 4-week course of the first-year undergraduate medical curriculum, which takes place twice in an academic year. One group of students (n=210) received a normal EBM-module in November. A practice-based EBM-module was implemented in January for another group of students (n=130). We approached all students following the courses for participation in our research project. In a quasi-experimental design, a validated survey was used to assess students' EBM task value and self-efficacy on a 7-point Likert-scale. In the experimental group, complementary qualitative data were gathered on attitude and motivation by open evaluative questions. RESULTS: Overall response rate was 93,5%, resulting in 191 students in the control group and 127 students in the experimental group. We did not find differences between the groups in terms of EBM task value and self-efficacy. However, the experimental group showed a higher increased perception of the importance of EBM in decision making in clinical practice (60.0% vs 77.2%; χ2(1, N=318) = 8.432, p=0.004). These students obtained a better understanding of the complexities and time-consuming nature of EBM in medical practice. CONCLUSIONS: The practice-based EBM-course helps students to reflect on practice and knowledge critically. Our findings indicate that integrating clinical practice in the undergraduate learning environment fosters attitude and motivation, suggesting that practice-based learning in EBM education may advance student development as a critically reflective practitioner.