Alignment of learning objectives, assessments, and active learning to promote critical thinking in a first-year medical physiology course: lessons learned.

Medical students must be adept at critical thinking to successfully meet the learning objectives of their preclinical coursework. To encourage student success on assessments, the course director of a first-year medical physiology course emphasized the use of learning objectives that were explicitly aligned with formative assessments in class. The course director introduced the physiology discipline, learning objectives, and evidence-based methods of studying to students on the first day of class. Thereafter, class sessions started with a review of the learning objectives for that session and included active learning opportunities such as retrieval practice. The instructor provided short answer formative assessments aligned with the learning objectives, intended to help the students apply and integrate the concepts. Midsemester, students received a link to an online survey with questions on studying habits, class attendance, and student engagement. After finals, students were invited to participate in focus groups about their class experience. A qualitative researcher moderated focus groups, recorded responses, and analyzed the narrative data. Of 175 students, 95 submitted anonymous online surveys. Student engagement was significantly correlated with in-person class attendance (r = 0.26, T = 2.5, P = 0.01) and the completion of open-ended formative assessments (r = 0.33, T = 3.3, P = 0.001). Focus groups were held via videoconference. From the class, 14 students participated in 4 focus groups; focus group participants were mostly women (11 of 14) and mostly in-class attendees (13 of 14). The students in this sample valued critical thinking but misunderstood expectations on exams and few students used learning objectives to study.NEW & NOTEWORTHY We introduced formative assessments and study techniques to first-year medical students in a physiology course. Mastery of learning objectives was emphasized as the key to success. We asked how they studied physiology through an anonymous online survey and focus group interviews. The students enjoyed physiology but had difficulty with exam expectations. Helping students use learning objectives to guide their study may lead to improved exam scores. It may also help administrators meet their curriculum goals.

"Who wants me to do what?" varied expectations from key stakeholder groups in the surgical intensive care unit creates a challenging learning environment.

BACKGROUND: Surgical intensive care units (SICU) require complex care from a multi-disciplinary team. Frequent changes in team members can lead to shifting expectations for junior general surgical trainees, which creates a challenging working and learning environment. We aim to identify expectations of junior surgery trainee's medical knowledge and technical/non-technical skills at the start of their SICU rotation. We hypothesize that expectations will not be consistent across SICU stakeholder groups. METHODS: Twenty-eight individual semi-structured interviews were conducted with six SICU stakeholder groups at a medium-sized academic hospital. Expectations were identified from interview transcripts. Frequency counts were analyzed. RESULTS: Forty-one expectations were identified. 4 expectations were identified by a majority of interviewees. Most expectations were identified by 7 or fewer interviewees. 23 (53%) expectations were shared by at least one stakeholder group. 2 (8%) expectations were shared by all groups. CONCLUSIONS: SICU stakeholder groups identified ten medical knowledge, ten technical skill, and three non-technical skill expectations. Yet, few expectations were shared among the groups. Thus, SICU stakeholder groups have disparate expectations for surgery trainees in our SICU.

Physicians' perspectives on continuity of care for patients involved in the criminal justice system: A qualitative study.

BACKGROUND: In 2016, over 11 million individuals were admitted to prisons and jails in the United States. Because the majority of these individuals will return to the community, addressing their health needs requires coordination between community and correctional health care providers. However, few systems exist to facilitate this process and little is known about how physicians perceive and manage these transitions. OBJECTIVE: The goal of this study was to characterize physicians' views on transitions both into and out of incarceration and describe how knowledge of a patient's criminal justice involvement impacts patient care plans. METHODS: Semi-structured interviews were conducted between October 2018 and May 2019 with physicians from three community clinics in Hennepin County, Minnesota. Team members used a hybrid approach of deductive and inductive coding, in which a priori codes were defined based on the interview guide while also allowing for data-driven codes to emerge. RESULTS: Four themes emerged related to physicians' perceptions on continuity of care for patients with criminal justice involvement. Physicians identified disruptions in patient-physician relationships, barriers to accessing prescription medications, disruptions in insurance coverage, and problems with sharing medical records, as factors contributing to discontinuity of care for patients entering and exiting incarceration. These factors impacted patients differently depending on the direction of the transition. CONCLUSIONS: Our findings identified four disruptions to continuity of care that physicians viewed as key barriers to successful transitions into and out of incarceration. These disruptions are unlikely to be effectively addressed at the provider level and will require system-level changes, which Medicaid and managed care organizations could play a leading role in developing.

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

BACKGROUND: Errors in reasoning are a common cause of diagnostic error. However, it is difficult to improve performance partly because providers receive little feedback on diagnostic performance. Examining means of providing consistent feedback and enabling continuous improvement may provide novel insights for diagnostic performance. METHODS: We developed a model for improving diagnostic performance through feedback using a six-step qualitative research process, including a review of existing models from within and outside of medicine, a survey, semistructured interviews with individuals working in and outside of medicine, the development of the new model, an interdisciplinary consensus meeting, and a refinement of the model. RESULTS: We applied theory and knowledge from other fields to help us conceptualise learning and comparison and translate that knowledge into an applied diagnostic context. This helped us develop a model, the Diagnosis Learning Cycle, which illustrates the need for clinicians to be given feedback about both their confidence and reasoning in a diagnosis and to be able to seamlessly compare diagnostic hypotheses and outcomes. This information would be stored in a repository to allow accessibility. Such a process would standardise diagnostic feedback and help providers learn from their practice and improve diagnostic performance. This model adds to existing models in diagnosis by including a detailed picture of diagnostic reasoning and the elements required to improve outcomes and calibration. CONCLUSION: A consistent, standard programme of feedback that includes representations of clinicians' confidence and reasoning is a common element in non-medical fields that could be applied to medicine. Adapting this approach to diagnosis in healthcare is a promising next step. This information must be stored reliably and accessed consistently. The next steps include testing the Diagnosis Learning Cycle in clinical settings.

Teamwork in clinical reasoning - cooperative or parallel play?

Teamwork is fundamental for high-quality clinical reasoning and diagnosis, and many different individuals are involved in the diagnostic process. However, there are substantial gaps in how these individuals work as members of teams and, often, work is done in parallel, rather than in an integrated, collaborative fashion. In order to understand how individuals work together to create knowledge in the clinical context, it is important to consider social cognitive theories, including situated cognition and distributed cognition. In this article, the authors describe existing gaps and then describe these theories as well as common structures of teams in health care and then provide ideas for future study and improvement.

Communication Deficits Among Surgical Residents During Difficult Patient Family Conversations.

OBJECTIVES: To qualitatively analyze videotaped data of surgical residents and fellows interacting with standardized patients to identify communication weaknesses. To correlate our qualitative data with their quantitative scores. DESIGN: We used discourse analysis to identify negative communication patterns among 10 surgical residents and fellows who were tested on interpersonal competencies during an objective structured clinical examination in 2014. We then correlated our findings with the validated evaluation outcomes. Descriptive statistics were then used to quantify our findings. SETTING: The setting was an objective structured clinical examination performed in 2014 using standardized patient surrogate family members. PARTICIPANTS: The participants were a mix of first and third year surgical residents and critical care fellows. RESULTS: The item that most strongly differentiated the bottom 5 from the top 5 performers was not answering the patient appropriately. This was exhibited in 3 ways among the lowest performers in our study: (1) paternalism, (2) vagueness, and (3) dehumanization. Our statistical analyses showed that the overall number of negative communication behaviors correlated with negative staff scores (r = -0.653, p < 0.05). Dehumanization and paternalism were the 2 behaviors most strongly correlated with negative staff scores (r = 0.796 and 0.781 respectively, p < 0.01). CONCLUSIONS: We found the lowest performers responded inappropriately to the patient, which we further delineated into vagueness, paternalism, and dehumanization. We propose positive communication strategies be taught to residents to improve how they are perceived by patients.

Using Implementation Science to Adapt a Training Program to Assist Surgeons with High-Stakes Communication.

OBJECTIVE: Surgeons often conduct difficult conversations with patients near the end of life, yet surgical education provides little formalized communication training. We developed a communication tool, Best Case/Worst Case, and trained surgeons using a one-on-one resource intensive format that was effective but difficult to scale for widespread dissemination. We aimed to generate an implementation package to teach surgeons using fewer resources without sacrificing fidelity. DESIGN, SETTING, AND PARTICIPANTS: We used the Replicating Effectiveness Programs framework to guide our implementation strategy and tested our intervention with 39 surgical residents at 4 institutions from September 2016 to June 2017. The implementation package consisted of: (1) instructional video, (2) checklist to assess competence, (3) learner manual, and (4) instructor manual. We focused on 3 implementation outcomes: feasibility, fidelity, and acceptability to participants. RESULTS: Attendance rates ranged from 16% to 75%. Site leaders had little difficulty identifying suitable instructors; however, resident recruitment proved challenging. Sixty-nine percent of residents completed the post-training assessment and the mean score was 12.8 (range 8-15) using the 15-point checklist. Across sites, 69% strongly agreed that Best Case/Worst Case is better than how they usually approach high-stakes conversations and 100% felt prepared to use the tool after training. Instructors reported that the training provided residents with the necessary skills to perform the fundamental elements of Best Case/Worst Case. CONCLUSIONS: Using implementation science we demonstrated that a resource intensive communication training intervention can be successfully modified for group-learning and wide-scale dissemination. However, we identified barriers to implementation, including challenges with feasibility and programmatic buy-in that inform not only resident education but also communication skills training more broadly.

Improving surgical residents' communication in disclosing complications: A qualitative analysis of simulated physician and patient surrogate conversations.

BACKGROUND: In this study, we explore surgical resident communication with simulated patient surrogates (SPs), in an Objective Structured Clinical Examination (OSCE). METHODS: We use discourse analysis (DA), a qualitative approach to analyzing language, to evaluate our residents' interactions with simulated patient surrogates. After identifying problematic communication patterns, we apply communication theory to discuss our findings and provide suggestions for improvement. RESULTS: Residents consistently use bluntness, defined as delivering the news abruptly and without adequate preface, and evasiveness, defined as avoiding giving the news, to deliver difficult information. In addition, some residents use neutral language when empathetic language is warranted; and some try to direct the response of SPs, who then become defensive. Residents use evasiveness most frequently, followed by bluntness. These delivery methods often result in poor communication. CONCLUSIONS: We recommend further research in barriers to effective resident communication with patients, as well as future research on the positive effects of good communication on patient perception. Learning these skills will help residents to convey support and empathy to patients, thereby enhancing care.