Optimizing allocation of curricular content across the Undergraduate & Graduate Medical Education Continuum.

BACKGROUND: Medical educators struggle to incorporate socio-cultural topics into crowded curricula. The "continuum of learning" includes undergraduate and graduate medical education. Utilizing an exemplar socio-cultural topic, we studied the feasibility of achieving expert consensus among two groups of faculty (experts in medical education and experts in social determinants of health) on which aspects of the topic could be taught during undergraduate versus graduate medical education. METHODS: A modified Delphi method was used to generate expert consensus on which learning objectives of social determinants of health are best taught at each stage of medical education. Delphi respondents included experts in medical education or social determinants of health. A survey was created using nationally published criteria for social determinants of health learning objectives. Respondents were asked 1) which learning objectives were necessary for every physician (irrespective of specialty) to develop competence upon completion of medical training and 2) when the learning objective should be taught. Respondents were also asked an open-ended question on how they made the determination of when in the medical education continuum the learning objective should be taught. RESULTS: 26 out of 55 experts (13 social determinants of health and 13 education experts) responded to all 3 Delphi rounds. Experts evaluated a total of 49 learning objectives and were able to achieve consensus for at least one of the two research questions for 45 of 49 (92%) learning objectives. 50% more learning objectives reached consensus for inclusion in undergraduate (n = 21) versus graduate medical education (n = 14). CONCLUSIONS: A modified Delphi technique demonstrated that experts could identify key learning objectives of social determinants of health needed by all physicians and allocate content along the undergraduate and graduate medical education continuum. This approach could serve as a model for similar socio-cultural content. Future work should employ a qualitative approach to capture principles utilized by experts when making these decisions.

Defining curricular priorities for student-as-teacher programs: A National Delphi Study.

BACKGROUND: "Student-as-Teacher" (SaT) programs have been growing in number to prepare medical students for their teaching roles in residency and beyond, but it remains unknown what content areas should be covered in SaT curricula. AIM: To determine five to ten "essential" content areas for inclusion in SaT curricula using expert opinion. METHODS: Using a three-round Delphi process, moderators iteratively surveyed a panel of 28 medical educators (25 academy directors and three individuals identified as having expertise in undergraduate medical education) representing 25 medical schools in the United States. This "SaT Delphi Working Group" was tasked with rating topics for inclusion in SaT curricula on a 3-point scale (i.e. 1. "essential," 2. "important, but not essential" 3. "not important"). Topics achieving ≥70% consensus as "essential," "important" or "not important" were accepted by the moderators and removed from subsequent rounds. RESULTS: Hundred per cent response rate (n = 28) was achieved for all survey rounds. Five content areas reached consensus as "essential" for inclusion in a SaT curriculum: feedback, bedside teaching and clinical precepting, small-group teaching, case-based teaching and professionalism as a medical educator. CONCLUSION: This consensus from a group of leaders in medical education is a first step toward the implementation of more developmentally-appropriate SaT competencies.

Transition to Residency Courses: Recommendations for Creation and Implementation.

Transition to Residency (TTR) courses help ease the critical transition from medical school to residency, yet there is little guidance for developing and running these courses. In this perspective, the authors use their expertise as well as a review of the literature to provide guidance and review possible solutions to challenges unique to these courses. TTR courses should be specialty-specific, allow for flexibility, and utilize active learning techniques. A needs assessment can help guide course content, which should focus on what is necessary to be ready for day one of residency. The use of residents in course planning and delivery can help create a sense of community and ensure that content is practical. While course assessments are largely formative, instructors should anticipate the need for remediation, especially for skills likely to be performed with limited supervision during residency. Additionally, TTR courses should incorporate learner self-assessment and goal setting; this may be valuable information to share with learners' future residency programs. Lastly, TTR courses should undergo continuous quality improvement based on course evaluations and surveys. These recommendations are essential for effective TTR course implementation and improvement.

Mistreatment and the Learning Environment: A Mixed Methods Approach to Assess Knowledge and Raise Awareness Amongst Residents.

OBJECTIVE: Trainee mistreatment, either intentional or unintentional, negatively affects the learning environment. This study was undertaken to evaluate the impact of an educational intervention about mistreatment and the learning environment on general surgery residents. DESIGN: Video-based modules were developed and added to the residency curriculum. Modules provided definitions and examples of active and passive mistreatment and components of positive and negative learning environments. A mixed-methods approach was used to assess the impact of this intervention. Residents completed a previously validated pre and post-test of related knowledge and attitudes (Abuse Sensitivity Questionnaire). Wilcoxon Signed Rank test was used to compare test results. During video-review sessions, discussion was prompted amongst residents using a semistructured interview guide. Immersion crystallization method was used to identify dominant themes. SETTING: Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS: All general surgery residents in our institution (n = 58) were invited to complete a survey at 3 time points. RESULTS: Fifty-eight residents (55% male) responded to the survey (100% response rate). Mean age was 30.2 year (SD 3.9). Perception of nicknames related to personal identifiers (p = 0.0065) and name-calling (p = 0.02) changed significantly postintervention (Table 1). Regarding standards of behavior, 42 (72.4%) residents considered yelling not to be abusive unless it occurred frequently or constantly; 15 (25.8%) residents considered swearing (not directed at a person) as "not abuse"; 6 (10.3%) considered constructive criticism to be abusive if it was frequent or constant; and 24 (41%) residents feel powerless to intervene in these scenarios. Multiple themes emerged regarding resident-student interactions: (1) resident perception that description of behavior as mistreatment depends on medical student sensitivity; (2) neglect of medical students avoids trouble (e.g., being labeled as active mistreatment); (3) failure to integrate students into the surgical team may occur due to perceived lack of student interest; and (4) communication with the medical student is key. Residents reported that discussion along with video review was more effective than video review alone. CONCLUSIONS: The video-based curriculum on mistreatment and the learning environment created awareness amongst residents about this important topic. Knowledge and attitudes about mistreatment changed in some areas postintervention. These findings suggest a need for development of complementary curricula to improve resident awareness and understanding of components of a positive learning environment and definition/examples of mistreatment.

Mistreatment and the learning environment for medical students on general surgery clerkship rotations: What do key stakeholders think?

BACKGROUND: Mistreatment has potential downstream effects on students. General surgery rotations tend to have a higher incidence of mistreatment reports. This study was undertaken to identify dominant themes contributing to a negative learning environment. METHODS: A qualitative study was performed using Delphi consensus technique to develop a discussion guide. Four focus groups were performed (n = 30 participants) with medical students, residents, nurses, and attending surgeons. Participants were selected using purposive-stratified criterion-based sampling. RESULTS: Multiple themes emerged: 1) unclear expectations for medical students; 2) passive mistreatment (neglect); 3) failure to integrate students into surgical team; 4) witnessed or experienced active mistreatment, 5) negative attitude of residents towards medical students' lack of knowledge. CONCLUSIONS: Medical student mistreatment persists and is a threat to the learning environment and individual learning process. Passive mistreatment (neglect) represents the most distressing component of mistreatment. These findings suggest a need for education aimed at surgical residents and others in the learning environment.