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INTRODUCTION: Uncertainty is integral to clinical practice and clinical reasoning but has proven difficult to study and model. Little is known about how clinicians manage uncertainty. According to evidence-based medicine theory, clinicians should utilise new information to reduce uncertainty until reaching action thresholds for further information gathering or treatment. We examined the impact of experience and task framing on uncertainty thresholds and the extent to which these thresholds guided clinical decisions. Finally, we sought to determine the impact of framing by having participants provide threshold responses as a range or as specific numbers. METHODS: One hundred sixty-eight fourth-year medical students, 93 residents and 72 faculty were presented a case of viral pneumonia with a suspected superimposed bacterial infection. Participants identified their testing and treatment thresholds with either a specific number or an inter-threshold range of probabilities that would compel them to test further. Afterwards, they were told the patient had a 20% pre-test probability of a superimposed infection and asked whether they would treat the patient with antibiotics, order additional testing or neither. Responses were compared with their previously stated threshold values to assess decision-making consistency. RESULTS: Testing thresholds were 15.8%, 20.6% and 25.8%, treatment thresholds were 78.5%, 71.6% and 73.4% and threshold spans (difference between testing and treatment thresholds) were 62.7, 51 and 47.6 for students, residents and faculty, respectively. Sixty-four percent of respondents made judgements consistent with their thresholds, 28% escalated their decision (doing more than their thresholds predicted) and 7.6% de-escalated their decision (doing less than their thresholds predicted). Framing had an impact on both faculty and resident decisions and a larger impact on students. DISCUSSION: These findings help us understand how clinical reasoning and threshold determinations vary with clinical experience. As uncertainty can lead to unnecessary testing and cognitive discomfort, examining decision thresholds helps us ascertain how diagnostic and treatment decisions are made.
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Pneumonia Viral , Estudantes de Medicina , Raciocínio Clínico , Humanos , Probabilidade , IncertezaRESUMO
BACKGROUND: The novel coronavirus disease was declared a pandemic in March 2020, which necessitated adaptations to medical education. This systematic review synthesises published reports of medical educational developments and innovations that pivot to online learning from workplace-based clinical learning in response to the pandemic. The objectives were to synthesise what adaptations/innovation were implemented (description), their impact (justification), and 'how' and 'why' these were selected (explanation and rationale). METHODS: The authors systematically searched four online databases up to December 21, 2020. Two authors independently screened titles, abstracts and full-texts, performed data extraction, and assessed the risk of bias. Our findings are reported in alignment with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance. RESULTS: Fifty-five articles were included. Most were from North America (n = 40), and nearly 70% focused on undergraduate medical education (UGME). Key developments were rapid shifts from workplace-based learning to virtual spaces, including online electives, telesimulation, telehealth, radiology, and pathology image repositories, live-streaming or pre-recorded videos of surgical procedures, stepping up of medical students to support clinical services, remote adaptations for clinical visits, multidisciplinary team meetings and ward rounds. Challenges included lack of personal interactions, lack of standardised telemedicine curricula and need for faculty time, technical resources, and devices. Assessment of risk of bias revealed poor reporting of underpinning theory, resources, setting, educational methods, and content. CONCLUSIONS: This review highlights the response of medical educators in deploying adaptations and innovations. Whilst few are new, the complexity, concomitant use of multiple methods and the specific pragmatic choices of educators offers useful insight to clinical teachers who wish to deploy such methods within their own practice. Future works that offer more specific details to allow replication and understanding of conceptual underpinnings are likely to justify an update to this review.
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COVID-19 , Educação a Distância , Educação Médica , Humanos , Pandemias , Local de TrabalhoRESUMO
BACKGROUND: The COVID-19 pandemic spurred an abrupt transition away from in-person educational activities. This systematic review investigated the pivot to online learning for nonclinical undergraduate medical education (UGME) activities and explored descriptions of educational offerings deployed, their impact, and lessons learned. METHODS: The authors systematically searched four online databases and conducted a manual electronic search of MedEdPublish up to December 21, 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias. A third author resolved discrepancies. Findings were reported in accordance with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance. RESULTS: Fifty-six articles were included. The majority (n = 41) described the rapid transition of existing offerings to online formats, whereas fewer (n = 15) described novel activities. The majority (n = 27) included a combination of synchronous and asynchronous components. Didactics (n = 40) and small groups (n = 26) were the most common instructional methods. Teachers largely integrated technology to replace and amplify rather than transform learning, though learner engagement was often interactive. Thematic analysis revealed unique challenges of online learning, as well as exemplary practices. The quality of study designs and reporting was modest, with underpinning theory at highest risk of bias. Virtually all studies (n = 54) assessed reaction/satisfaction, fewer than half (n = 23) assessed changes in attitudes, knowledge or skills, and none assessed behavioral, organizational or patient outcomes. CONCLUSIONS: UGME educators successfully transitioned face-to-face instructional methods online and implemented novel solutions during the COVID-19 pandemic. Although technology's potential to transform teaching is not yet fully realized, the use of synchronous and asynchronous formats encouraged virtual engagement, while offering flexible, self-directed learning. As we transition from emergency remote learning to a post-pandemic world, educators must underpin new developments with theory, report additional outcomes and provide details that support replication.
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COVID-19 , Educação a Distância , Educação de Graduação em Medicina , COVID-19/epidemiologia , Humanos , Pandemias , SARS-CoV-2RESUMO
BACKGROUND: Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners. METHODS: Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned. RESULTS: Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities (n Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment. CONCLUSIONS: This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.
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COVID-19 , Educação Médica , COVID-19/epidemiologia , Competência Clínica , Atenção à Saúde , Humanos , PandemiasRESUMO
BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.
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COVID-19 , Educação Médica , Internato e Residência , Humanos , Pandemias , COVID-19/epidemiologia , Educação de Pós-Graduação em Medicina , Bolsas de EstudoRESUMO
BACKGROUND: As a community of practice (CoP), medical education depends on its research literature to communicate new knowledge, examine alternative perspectives, and share methodological innovations. As a key route of communication, the medical education CoP must be concerned about the rigor and validity of its research literature, but prior studies have suggested the need to improve medical education research quality. Of concern in the present study is the question of how responsive the medical education research literature is to changes in the CoP. We examine the nature and extent of changes in the quality of medical education research over a decade, using a widely cited study of research quality in the medical education research literature as a benchmark to compare more recent quality indicators. METHODS: A bibliometric analysis was conducted to examine the methodologic quality of quantitative medical education research studies published in 13 selected journals from September 2013 to December 2014. Quality scores were calculated for 482 medical education studies using a 10-item Medical Education Research Study Quality Instrument (MERSQI) that has demonstrated strong validity evidence. These data were compared with data from the original study for the same journals in the period September 2002 to December 2003. Eleven investigators representing 6 academic medical centers reviewed and scored the research studies that met inclusion and exclusion criteria. Primary outcome measures include MERSQI quality indicators for 6 domains: study design, sampling, type of data, validity, data analysis, and outcomes. RESULTS: There were statistically significant improvements in four sub-domain measures: study design, type of data, validity and outcomes. There were no changes in sampling quality or the appropriateness of data analysis methods. There was a small but significant increase in the use of patient outcomes in these studies. CONCLUSIONS: Overall, we judge this as equivocal evidence for the responsiveness of the research literature to changes in the medical education CoP. This study identified areas of strength as well as opportunities for continued development of medical education research.
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Pesquisa Biomédica , Educação Médica , Bibliometria , Educação em Saúde , Humanos , Projetos de PesquisaRESUMO
The use of telemedicine in clinical care has grown significantly in the last few years and has only increased during the COVID-19 pandemic. Given that many physicians will be expected to deliver virtual care moving forward, it is important for medical students to gain exposure via this modality during their clinical training. Many medical schools are actively working to integrate students into telemedicine. This article aims to provide guidance for readers incorporating medical students in telemedicine visits at an institutional or departmental level. This article covers essential topics such as coordinating key stakeholders, conducting needs assessments, addressing technological or software considerations, and creating appropriate workflows for students and physicians.
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COVID-19 , Educação de Graduação em Medicina , Estudantes de Medicina , Telemedicina , Currículo , Humanos , Pandemias , SARS-CoV-2RESUMO
BACKGROUND: COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research. METHODS: The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts. RESULTS: One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning (n = 58), simulation (n = 24), assessment (n = 11), well-being (n = 8), telehealth (n = 5), clinical service reconfigurations (n = 4), interviews (n = 4), service provision (n = 2), faculty development (n = 2) and other (n = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement). CONCLUSIONS: This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.
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COVID-19/epidemiologia , Educação a Distância/tendências , Educação Médica/tendências , Medicina Baseada em Evidências/estatística & dados numéricos , Pessoal de Saúde/educação , Telemedicina/tendências , Ásia , COVID-19/terapia , Competência Clínica , Europa (Continente) , Humanos , América do Norte , Simulação de Paciente , Estudantes de Ciências da Saúde/estatística & dados numéricosRESUMO
PURPOSE: Educational approaches involving patient stories aim at enhancing empathy and patient-centered care; however, it is not known whether the influence of such programs on physician attitudes persists beyond medical school. MATERIALS AND METHODS: The Family Centered Experience (FCE) paired preclinical medical students with patient families over two years and engaged students in reflective dialogs about the volunteers' stories. This study examined possible long-term influences on attitudes toward medicine and doctoring. Interviews were conducted with former students at the end of or after post-graduate training. All had completed the FCE between 4 and 10 years before the study. Thematic analysis was informed by a constructivist Grounded Theory approach. RESULTS: Several themes were identified. The FCE made graduates aware of the patients' perspectives and impacted their clinical practice in specific ways, such as developing collaborative partnerships, conducting family meetings, and breaking bad news. The course had influenced career choices and interest in teaching. Finally, the FCE enhanced appreciation of the human dimensions of medicine, which graduates had drawn upon in subsequent years. CONCLUSIONS: A program based on longitudinal interactions with individuals with chronic illness can have persistent influence by stimulating reflection on the patient's perspective and humanistic approaches to patient care.
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Competência Clínica/normas , Currículo/normas , Educação Médica/métodos , Narração , Assistência Centrada no Paciente/normas , Relações Médico-Paciente , Feminino , Humanos , Masculino , Estudantes de MedicinaRESUMO
PURPOSE: This study investigates the contributions of self-assessment (SA) and external feedback on the development of learning goals (LG) and the influence on LG recall and implementation in medical students. METHODS: Following a standardized patient (SP) assessment, 168 pre-clinical medical students completed a SA, received SP feedback and created a LG. LG were categorized by source. Two weeks later, students recalled LG and described implementation. Chi-squared analyses were used to test the associations. RESULTS: SA influenced LG for 82.8% of students whereas SP feedback influenced LG for 45.9%. Students rarely generated LG based on SA when they received discordant feedback (5.4%), but sometimes incorporated feedback discordant from their SA into LG (14.9%). Students who created LG based on SP feedback were more likely to recall LG than those who created LG based on SA, 89.7 versus 67.6%, p < 0.05 and implement their LG, 72.4 versus 48.9%, χ2(1) = 5.3, p = 0.017. Students who reported receiving effective feedback were more likely to implement their LG than those reporting adequate feedback, 60.9 versus 37.9%, χ2(1) = 8.0, p = 0.01. CONCLUSIONS: SA is an essential part of goal setting and subsequent action. Perception of feedback plays a crucial role in LG implementation.
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Objetivos , Aprendizagem , Autoavaliação (Psicologia) , Estudantes de Medicina/psicologia , Feedback Formativo , HumanosRESUMO
OBJECTIVES: Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training. METHODS: About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05. RESULTS: About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05). CONCLUSIONS: This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.
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Competência Clínica , Educação de Graduação em Medicina/métodos , Internato e Residência/estatística & dados numéricos , Transferência da Responsabilidade pelo Paciente , Comunicação , Avaliação Educacional , Retroalimentação , Feminino , Humanos , Masculino , Medicina , Avaliação de Programas e Projetos de SaúdeRESUMO
The clinical learning environment (CLE) encompasses the learner's personal characteristics and experiences, social relationships, organizational culture, and the institution's physical and virtual infrastructure. During the COVID-19 pandemic, all 4 of these parts of the CLE have undergone a massive and rapid disruption. Personal and social communications have been limited to virtual interactions or shifted to unfamiliar clinical spaces because of redeployment. Rapid changes to the organizational culture required prompt adaptations from learners and educators in their complex organizational systems yet caused increased confusion and anxiety among them. A traditional reliance on a physical infrastructure for classical educational practices in the CLE was challenged when all institutions had to undergo a major transition to a virtual learning environment. However, disruptions spurred exciting innovations in the CLE. An entire cohort of physicians and learners underwent swift adjustments in their personal and professional development and identity as they rose to meet the clinical and educational challenges they faced due to COVID-19. Social networks and collaborations were expanded beyond traditional institutional walls and previously held international boundaries within multiple specialties. Specific aspects of the organizational and educational culture, including epidemiology, public health, and medical ethics, were brought to the forefront in health professions education, while the physical learning environment underwent a rapid transition to a virtual learning space. As health professions education continues in the era of COVID-19 and into a new era, educators must take advantage of these dynamic systems to identify additional gaps and implement meaningful change. In this article, health professions educators and learners from multiple institutions and specialties discuss the gaps and weaknesses exposed, opportunities revealed, and strategies developed for optimizing the CLE in the post-COVID-19 world.
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COVID-19/prevenção & controle , Educação a Distância/métodos , Educação Médica/métodos , Aprendizagem , Distanciamento Físico , Estudantes de Medicina/psicologia , Comportamento Cooperativo , Educação a Distância/organização & administração , Educação Médica/organização & administração , Humanos , Práticas Interdisciplinares , Cultura Organizacional , Meio Social , Rede Social , Estados UnidosAssuntos
Dermatite/etiologia , Exantema/etiologia , Zinco/deficiência , Anti-Inflamatórios/uso terapêutico , Diagnóstico Diferencial , Humanos , Lactente , Masculino , Leite Humano/química , Creme para a Pele , Triancinolona/uso terapêutico , Sulfato de Zinco/análise , Sulfato de Zinco/uso terapêuticoAssuntos
Hepatite Viral Humana/diagnóstico , Infecções por Vírus Respiratório Sincicial/diagnóstico , Vírus Sinciciais Respiratórios/isolamento & purificação , Dor Abdominal/diagnóstico , Diagnóstico Diferencial , Dispneia/diagnóstico , Feminino , Hepatite Viral Humana/terapia , Hepatite Viral Humana/virologia , Humanos , Lactente , Infecções por Vírus Respiratório Sincicial/terapia , Infecções por Vírus Respiratório Sincicial/virologiaRESUMO
BACKGROUND: The continuously changing health care context necesitates that medical trainees develop self-directed learning skills. This study examined the effect of coaching on the self-directed learning process in pre-clerkship medical students. METHODS: We conducted a longitudinal educational intervention using standardised patient assessments to determine the effect of self-assessment, feedback, and coaching on the development and implementation of learning goals (LGs). Students were sorted into control and intervention groups. Following each assessment, students received feedback on performance and created LGs. Students in the intervention group worked with a faculty member coach on their LGs. Students in the control group developed their LGs without a coach. Prior to the final assessment, students reported whether they had implemented their LGs. RESULTS: Of 171 students enrolled, 167 completed all four assessments and were included. All 167 developed an LG after each assessment. Overall, 79.0% of students reported implementing an LG. Of students receiving coaching, 91.8% implemented an LG, whereas only 65.9% of students in the control group implemented an LG (odds ratio, OR 5.7; 95% confidence interval, CI 2.4-14.2). Students who received coaching were more likely to incorporate performance feedback into their LGs (90.2 versus 38.1%; p < 0.05). CONCLUSIONS: For students, faculty member coaching facilitated better LG development and more frequent implementation compared with students who did not receive coaching.
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Educação de Graduação em Medicina , Tutoria , Estudantes de Medicina , Educação de Graduação em Medicina/métodos , Humanos , Aprendizagem , Tutoria/métodos , Autoavaliação (Psicologia)RESUMO
This article was migrated. The article was marked as recommended. Introduction: Interdisciplinary co-teaching by physicians (MD) and social behavioural scientists (SBS) has emerged as an innovative teaching practice in clinical skills courses, but little is known about how co-teachers operationalize instruction. The purpose of this study was to explore the shared mental model of co-teachers concerning medical interviewing and physical examination instruction. Methods: Twelve individual semi-structured interviews were conducted at Brown University. Participants were asked, " What and how do MD and SBS faculty contribute to teaching medical interviewing and physical examination skills?" Transcripts were subjected to thematic analysis. Discourse analysis was also used to determine if what faculty individually described as contributing to instruction was observed by the co-teacher. Results: Physician and SBS faculty emphasized different but complementary aspects of medical interviewing and physical examination skills. Physicians focused on content, targeting clinical reasoning, differential diagnosis, economy of movement, efficiency, synthesis, and technical skills. SBS faculty focused on process,emphasizing active listening, presence, non-verbal communication, rapport building, empathy, and patient comfort. Discussion: Co-teachers consistently articulated their relative contributions to teaching medical interviewing and physical examinations. Their shared mental model emphasized the importance of both content and process, creating a learning environment supporting the development of both biomedical and patient-centred perspectives.
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PURPOSE: An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore the existing menu of CR assessments. METHOD: Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were sorted by assessment methods and reviewed by pairs of authors. Extracted data were used to construct descriptive appendixes, summarizing each method, including common stimuli, response formats, scoring, typical uses, validity considerations, feasibility issues, advantages, and disadvantages. RESULTS: A total of 377 articles were included in the final synthesis. The articles broadly fell into three categories: non-workplace-based assessments (e.g., multiple-choice questions, extended matching questions, key feature examinations, script concordance tests); assessments in simulated clinical environments (objective structured clinical examinations and technology-enhanced simulation); and workplace-based assessments (e.g., direct observations, global assessments, oral case presentations, written notes). Validity considerations, feasibility issues, advantages, and disadvantages differed by method. CONCLUSIONS: There are numerous assessment methods that align with different components of the complex construct of CR. Ensuring competency requires the development of programs of assessment that address all components of CR. Such programs are ideally constructed of complementary assessment methods to account for each method's validity and feasibility issues, advantages, and disadvantages.