The Impact of Role Models on Medical Students

Early learner perceptions of the attributes of effective preceptors

Medical education in the US has adapted to the shift of patient care from hospital to ambulatory settings by developing educational opportunities in outpatient settings. Faculty development efforts must acknowledge learners' perspectives to be effective in improving teaching and learning. Clinics provide important and unique learning opportunities, but also present different challenges for preceptors (i.e., physician teachers) and learners. Multiple studies have identified characteristics of effective preceptors of ambulatory care medicine. However, most of these studies were conducted among residents or students with clinical experience. To investigate preclinical, second-year medical students' perceptions of preceptor quality, we conducted an exploratory qualitative study using analysis of student learning journals. The purposive sample included 120 medical students in a private, Midwestern medical school in the United States. Learning journals of 110 students for two semesters were reviewed. Five attributes of an effective preceptor emerged: (1) Demonstrates professional expertise (2) Actively engages students in learning (3) Creates a positive environment for teaching and learning (4) Demonstrates collegiality and professionalism (5) Discusses career-related topics and concerns. Our findings suggest preclinical learners often begin initial clinical experiences with sophisticated definitions of professional expertise, and hold specific expectations for professionalism. These are based on previous coursework and personal experience. These expectations influence their perceptions of effective preceptors and learning experiences. Early clinical experiences can also influence perceptions about career and specialty choice. Improving our understanding of preclinical learners' perceptions of preceptor quality will improve the efficacy of faculty development efforts and learning experiences.

Students who wish to specialize in forensic medicine vs. their fellow students: motivations, attitudes and reactions during autopsy practice

PURPOSE

To investigate the particular features of students who express the desire to follow a forensic career.

METHODS AND MATERIALS

Three hundred and four 6th-year students attending the compulsory practice in forensic medicine in the academic year 2005-2006 were asked to fill in a self-administered questionnaire at the end of the course.

RESULTS

The predominant motivation for following forensics was the scientific interest (39.7%). Gender, marital status, religion, place of residence, number of siblings, father/mother being a health professional, being a religious individual were not associated with forensics. Higher grades were a negative predictor for the forensic specialty. A trend linking rejection of an afterlife and orientation towards forensic medicine was found. The fear of death was more intense in students rejecting forensics. Feelings of fear, aversion and grief during the last day of autopsy seemed to be important negative predictors. Stereotypes about forensic doctors (such as "forensic doctors have a peculiar character") significantly modified the decision of students, but the beliefs about the role of the autopsy practice (cause of anxiety for death, stimulus to live every moment in life) did not.

CONCLUSION

Medical students who want to follow forensics present only small differences concerning their inherent features, beliefs, reactions, emotions and attitudes, compared with the rest of their fellow students.

The impact of facilitation of small-group discussions of psychosocial topics in medicine on faculty growth and development

PURPOSE

To use qualitative analysis of interview transcripts with clinician-educators who facilitate small-group discussions on psychosocial themes--including doctoring--to answer the question, "What impact does facilitating small-group discussions of the patient's experience with chronic illness, the doctor-patient relationship, and doctoring have on faculty instructors' attitudes regarding their roles as clinicians and teachers?"

METHOD

In 2006, in-depth, face-to-face interviews using an open-ended question format were conducted with individual faculty small-group instructors teaching in the Family Centered Experience and Longitudinal Case Studies courses at the University of Michigan Medical School. Interview transcripts were analyzed using grounded theory methodology to identify emerging themes. Accuracy of interpretations and saturation of themes was confirmed by repeated contextual reading of the transcripts.

RESULTS

Several major thematic codes emerged from the data. Facilitation of small-group discussions of psychosocial topics and doctoring fostered reflective approaches to patient care and teaching; enhanced interpersonal relationships between facilitators and their students, colleagues, and patients; and acted as a source of fulfillment and renewal among faculty facilitators.

CONCLUSIONS

Small-group teaching of the art of doctoring may stimulate personal and professional growth among faculty facilitators and renewed interest in teaching and patient care.

Clinical excellence in academia: perspectives from masterful academic clinicians

OBJECTIVE

To better understand and characterize clinical excellence in academia by exploring the perspectives of clinically excellent faculty in the top American departments of medicine.

PARTICIPANTS AND METHODS

Between March 1 and May 31, 2007, 2 investigators conducted in-depth semistructured interviews with 24 clinically excellent Department of Medicine physicians at 8 academic institutions. Interview transcripts were independently analyzed by 2 investigators and compared for agreement. Content analysis identified several major themes that relate to clinical excellence in academia.

RESULTS

Physicians hailed from a range of internal medicine specialties; 20 (83%) were associate professors or professors and 8 (33%) were women. The mean percentage of time physicians spent in clinical care was 48%. Eight domains emerged as the major features of clinical excellence in academia: reputation, communication and interpersonal skills, professionalism and humanism, diagnostic acumen, skillful negotiation of the health care system, knowledge, scholarly approach to clinical care, and passion for clinical medicine.

CONCLUSION

Understanding the core elements that contribute to clinical excellence in academia represents a pivotal step to defining clinical excellence in this setting. It is hoped that such work will lead to initiatives aimed at measuring and rewarding clinical excellence in our academic medical centers such that the most outstanding clinicians feel valued and decide to stay in academia to serve as role models for medical trainees.

Internal medicine clerkship directors' perceptions about student interest in internal medicine careers

BACKGROUND

Experienced medical student educators may have insight into the reasons for declining interest in internal medicine (IM) careers, particularly general IM.

OBJECTIVE

To identify factors that, according to IM clerkship directors, influence students' decisions for specialty training in IM.

DESIGN

Cross-sectional national survey.

PARTICIPANTS

One hundred ten institutional members of Clerkship Directors in IM.

MEASUREMENTS

Frequency counts and percentages were reported for descriptive features of clerkships, residency match results, and clerkship directors' perceptions of factors influencing IM career choice at participating schools. Perceptions were rated on a five-point scale (1 = very much pushes students away from IM careers; 5 = very much attracts students toward IM careers).

RESULTS

Survey response rate was 83/110 (76%); 80 answered IM career-choice questions. Clerkship directors identified three educational items attracting students to IM careers: quality of IM faculty (mean score 4.3, SD = 0.56) and IM rotation (4.1, SD = 0.67), and experiences with IM residents (3.9, SD = 0.94). Items felt most strongly to push students away from IM careers were current practice environment for internists (mean score 2.1, SD = 0.94), income (2.1, SD = 1.08), medical school debt (2.3, SD = 0.89), and work hours in IM (2.4, SD = 1.05). Factor analysis indicated three factors explaining students' career choices: value/prestige of IM, clerkship experience, and exposure to internists.

CONCLUSIONS

IM clerkship directors believe that IM clerkship experiences attract students toward IM, whereas the income and lifestyle for practicing internists dissuade them. These results suggest that interventions to enhance the practice environment for IM could increase student interest in the field.

Can compassion be taught? Let's ask our students

BACKGROUND

Medical educators act on the belief that students benefit from formal and informal educational experiences that foster virtues such as compassion, altruism, and respect for patients.

OBJECTIVE

The purpose of this study is to examine fourth year medical students' perspectives on how, where, and by whom they believe the virtues associated with good physicianhood have been taught to them.

DESIGN

Fourth year students were assigned a two- to three-page essay that asked them to reflect on how their medical education had "fostered and hindered" their conceptions of compassion, altruism, and respect for patients.

PARTICIPANTS

All 112 students completed this assignment, and 52 (46%) gave us permission to use their essays for this study.

APPROACH

An inductive, qualitative approach was used to develop themes derived from students' essays.

RESULTS

Students' thoughts were organized around the idea of influences in three areas to which they consistently referred. Foundational influences included parents and "formative years," religious faith, and other experiences preceding medical school. Preclinical education influences comprised formal classroom experiences (both positive and negative effects). Clinical education influences included role modeling (both positive and negative) and the clinical environment (notable for emphasis on efficiency and conflicting cues). Students' essays drew most heavily on the effects of role modeling.

DISCUSSION

Medical students arrive at our doors as thoughtful, compassionate people. Positive role models and activities to promote critical self-reflection may help nurture these attitudes.

Do fears of malpractice litigation influence teaching behaviors?

BACKGROUND

Medical malpractice is prominently positioned in the consciousness of American physicians, and the perceived threat of malpractice litigation may push physicians to practice defensively and alter their teaching behaviors.

PURPOSE

The purposes of this study were to characterize the attitudes of academic medical faculty toward malpractice litigation and to identify teaching behaviors associated with fear of malpractice litigation.

METHODS

We surveyed 270 full-time clinically active physicians in the Department of Medicine at a large academic medical center. The survey assessed physicians' attitudes toward malpractice issues, fear of malpractice litigation, and self-reported teaching behaviors associated with concerns about litigation.

RESULTS

Two hundred and fifteen physicians responded (80%). Faculty scored an average of 25.5 +/- 6.9 (range = 6-42, higher scores indicate greater fear) on a reliable malpractice fear scale. Younger age (Spearman's rho = 0.19, p = .02) and greater time spent in clinical activities (rho = 0.26, p < .001) were correlated with higher scores on the Malpractice Fear Scale. Faculty reported that because of the perceived prevalence of lawsuits and claims made against physicians, they spend more time writing clinical notes for patients seen by learners (74%), give learners less autonomy in patient care (44%), and limit opportunities for learners to perform clinical procedures (32%) and deliver bad news to patients (33%). Faculty with higher levels of fear on the Malpractice Fear Scale were more likely to report changing their teaching behaviors because of this perceived threat (rho = 0.38, p < .001).

CONCLUSIONS

Physicians report changes in teaching behaviors because of concerns about malpractice litigation. Although concerns about malpractice may promote increased supervision and positive role modeling, they may also limit important educational opportunities for learners. These results may serve to heighten awareness to the fact that teaching behaviors and decisions may be influenced by the malpractice climate.

Operating room assist: surgical mentorship and operating room experience for preclerkship medical students

BACKGROUND

Despite the importance of preclerkship experiences, surgical education has essentially remained confined to the third-year operating room experience. According to experience-based learning theory, the acquisition of new clinical knowledge is a dynamic process of social enculturation and professional identity development that requires active participation, clinical applicability, and direct interaction with doctors and other members of the medical team. In conjunction with a previously described surgical skills elective, we created a new clinical elective in which preclerkship medical students were assigned a surgical mentor and invited into the operating room to assist in surgeries.

METHODS

The elective paired 36 first-year students with 24 surgeons and instructed students to participate in at least 2 surgeries over the 3-month elective period. Students, surgeons, and operating room nurses filled out questionnaires after each surgery.

RESULTS

Although 6 students failed to enter the operating room, 30 students scrubbed and gowned for a total of 62 procedures during the elective period. Although most students reported the operating room to be a comfortable learning environment in which they were actively included, students consistently underrated their performance and contribution to the surgical team compared with the surgeons' and nurses' ratings. With 75% of students who reported using a previously learned surgical skill during each surgery, this elective succeeded in allowing preclerkship medical students the opportunity to participate actively in the operating room.

CONCLUSIONS

Early surgical exposure is critical for attracting student interest in careers in surgery. We believe that these early clinical experiences, combined with strong mentorship from the surgical faculty, will eventually lead to greater success during clerkships and greater interest in surgery as a career.

Factors associated with the subspecialty choices of internal medicine residents in Canada

BACKGROUND

Currently, there are more residents enrolled in cardiology training programs in Canada than in immunology, pharmacology, rheumatology, infectious diseases, geriatrics and endocrinology combined. There is no published data regarding the proportion of Canadian internal medicine residents applying to the various subspecialties, or the factors that residents consider important when deciding which subspecialty to pursue. To address the concern about physician imbalances in internal medicine subspecialties, we need to examine the factors that motivate residents when making career decisions.

METHODS

In this two-phase study, Canadian internal medicine residents participating in the post graduate year 4 (PGY4) subspecialty match were invited to participate in a web-based survey and focus group discussions. The focus group discussions were based on issues identified from the survey results. Analysis of focus group transcripts grew on grounded theory.

RESULTS

110 PGY3 residents participating in the PGY4 subspecialty match from 10 participating Canadian universities participated in the web-based survey (54% response rate). 22 residents from 3 different training programs participated in 4 focus groups held across Canada. Our study found that residents are choosing careers that provide intellectual stimulation, are consistent with their personality, and that provide a challenge in diagnosis. From our focus group discussions it appears that lifestyle, role models, mentorship and the experience of the resident with the specialty appear to be equally important in career decisions. Males are more likely to choose procedure based specialties and are more concerned with the reputation of the specialty as well as the anticipated salary. In contrast, residents choosing non-procedure based specialties are more concerned with issues related to lifestyle, including work-related stress, work hours and time for leisure as well as the patient populations they are treating.

CONCLUSION

This study suggests that internal medicine trainees, and particularly males, are increasingly choosing procedure-based specialties while non-procedure based specialties, and in particular general internal medicine, are losing appeal. We need to implement strategies to ensure positive rotation experiences, exposure to role models, improved lifestyle and job satisfaction as well as payment schedules that are equitable between disciplines in order to attract residents to less popular career choices.

What makes a good clinical teacher in medicine? A review of the literature

PURPOSE

The authors perform a review of the literature pertinent to the question, "What makes a good clinical teacher in medicine?"

METHOD

After framing the question, based on discussions of their own experiences with clinical teachers, the authors performed a search of the literature pertinent to the question, "What are the qualities of a good clinical teacher in medicine?" Between July and December, 2006, they reviewed titles from Index Medicus (1909-1966), PubMed (1966 to the present), PubMed Related Articles, and referenced articles. The initial selections were chosen by scanning pre-1966 Index Medicus title lists and post-1966 abstracts. Chosen articles were then read in their entirety, and those which described specific characteristics of clinical teachers were selected for inclusion. Qualitative analysis was used to identify themes.

RESULTS

From 4,914 titles, 68 articles were selected for analysis-26 published before 1966, and 42 published after 1966. Four hundred eighty descriptors were identified and grouped into 49 themes, which were clustered into three main categories: physician, teacher, and human characteristics. Echoing the authors' intuitive descriptions, noncognitive characteristics dominated the descriptions and themes.

CONCLUSIONS

Excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students. Faculty development programs and future research should focus on development of the noncognitive attributes of clinical teachers, as well as the knowledge and skills associated with effective teaching.

Are surgical progeny more likely to pursue a surgical career?

BACKGROUND

For nearly two decades, interest in general surgery has been declining among U.S. medical school graduates. Many factors appear to be important in a medical student's choice of a surgical residency and career. We hypothesized that previous exposure to family members who are surgeons would significantly influence a student's decision to pursue a career in surgery.

METHODS

Since 2001, nearly 600 third-year medical students completing the general surgery clerkship were issued a pre- and post-clerkship survey. Responses were collected, retrospectively analyzed, and correlated to the 2001-2007 National Residency Matching Program match results.

RESULTS

The response rate of students completing both surveys was 87% (n = 510). Based on a numeric scale, surgical progeny (SP) indicated a significantly higher likelihood than nonsurgical progeny (NSP) of pursing a surgical career/residency in the pre-clerkship period (SP mean, 5.1 +/- 0.42; NSP mean, 3.7 +/- 0.11; P = 0.0005). Post-clerkship, SPs noted no more enjoyment from the surgical clerkship than NSPs (SP mean, 7.2 +/- 0.25; NSP mean, 6.9 +/- 0.96; P = 0.91); furthermore, there was no difference in the percentage of students pursuing a surgical residency (categorical or surgical subspecialty) in the National Residency Matching Program match (SP, 12.5%; NSP, 12.7%; P = 1.00).

CONCLUSION

These data suggest that previous exposure to a surgeon within the family positively influences a medical student's pre-clerkship interest in pursuing a surgical career. However, this interest is not sustained; SPs and NSPs match into surgical residencies at equivalent rates. Clearly, further studies are needed to identify the factors responsible for this phenomenon.

Junior medical students' notions of a 'good doctor' and related expectations: a mixed methods study

OBJECTIVE

To explore junior medical students' notions of a 'good doctor', given their ideas about: success in Year 1, house jobs, and their attraction to medicine.

METHODS

Study participants were junior medical students (1999 and 2001 entry cohorts studied thrice and twice, respectively) and prospective students of the University of Liverpool's 5-year, problem-based, community-orientated curriculum. Data collection and analysis used a 'mixed methods' approach, cross-sectional design, and brief questionnaire surveys. In an index survey, open questions (analysed inductively) explored house jobs and Year 1 success. They also generated 'good doctor' themes, which a second survey confirmed and 3 surveys ranked. A sixth survey explored motivation for choosing medicine (open question). Good doctor rankings were analysed by postcode for prospective medical students classified as school-leaver residents of England and Wales.

RESULTS

Response rates were: 91.4% (973) of the 2001-02 admission candidates, on interview days; 68.0% (155), 61.2% (137) and 77.9% (159) of the 1999 cohort (at entry, end-Year 1 and mid-Year 3, respectively), and 71.0% (201) and 71.0% (198) of the 2001 cohort (at entry and end-Year 1, respectively). From 9 themes generally compatible with self-reported motivations and expectations, junior and prospective medical students consistently valued a good doctor as a 'compassionate, patient-centred carer' and a 'listening, informative communicator' over an 'exemplary, responsible professional'. Prospective students from less affluent English and Welsh postcodes valued 'efficient, organised self-manager' very slightly more highly (r(s) = - 0.140, P = 0.003).

CONCLUSIONS

This research provided empirical evidence to support ongoing commentary about patients mostly seeking qualities related to communication, caring, and competence in doctors. Weak evidence that socio-economic status might affect notions of a good doctor is worth pursuing.

The new and improved learning community at Johns Hopkins University School of Medicine resembles that at Hogwarts School of Witchcraft and Wizardry

BACKGROUND

In July 2005, a learning community was created at Johns Hopkins University School of Medicine (JHUSOM) to foster camaraderie, networking, advising, mentoring, professionalism, clinical skills, and scholarship--The Colleges. The cultural and structural changes that emerged with the creation of this program have resulted in JHUSOM bearing a resemblance to J. K. Rowling's fictional Hogwarts School of Witchcraft and Wizardry.

AIMS

This manuscript will describe the similarities between these two revered schools, and highlight the innovations and improvements made to JHUSOM's learning environment.

DESCRIPTION

The intense, stressful, and lengthy professional training required to achieve competency in the practice of medicine and in the practice of witchcraft (albeit fictional) have meaningful parallels.

CONCLUSION

The supportive learning environment at these two schools should afford the next generation of graduates to have an even more enriching experience than those who have come before them.

A better lifestyle during surgical clerkship may not increase application rates to general surgery

BACKGROUND

Lifestyle has been identified by numerous studies as the number one deterrent to pursuing a career in general surgery. This study tests the hypothesis that a better lifestyle during general surgery clerkship correlates with a higher application rate to general surgery.

METHODS

Canadian Residency Matching Service data from the past 10 years were used to identify institution-specific application rates to general surgery. Through a survey of all fourth-year medical students applying to general surgery in Canada and Canadian undergraduate surgery program directors, the lifestyle of each general surgery clerkship was described and given a score.

RESULTS

Multiple descriptions of the clerkship structure were obtained for every school in Canada to reduce recall bias, with an average of 4 sources per program. One school stood out as the most prolific producer of general surgery applicants, with an average of 7.9% of the total class applying to general surgery each year. This represented 80% more general surgery applicants relative to the national average (p < 0.05). Surprisingly, however, this institution also had the worst clerkship lifestyle score, having a higher call requirement, not sending their clerks home at noon post call, and placing a higher burden of responsibility on their clerks.

CONCLUSIONS

This study suggests that a lifestyle-friendly surgical clerkship may not be necessary to increase recruitment into general surgery.

Factors influencing career choice in ophthalmology

BACKGROUND

To investigate the factors influencing choice of ophthalmology as a career in medicine.

METHODS

Data were extracted from the 2004 National Physician Survey, a questionnaire distributed to all physicians across Canada. Data were categorized by medical discipline, and chi2 comparative analyses were done.

RESULTS

Intellectual stimulation emerged as the most frequently cited factor influencing career choice for ophthalmologists and nonophthalmologists alike (81% and 79%, respectively). Compared with other physicians, ophthalmologists were significantly more likely to cite flexibility (58% vs. 42%, respectively), mentorship (42% vs. 31%, respectively), and earning potential (38% vs. 26%, respectively) as important factors (p<0.001).

INTERPRETATION

Intellectual stimulation is the principal reason physicians pursue a career in ophthalmology. Ophthalmologists cite flexibility, mentorship, and earning potential as important factors more frequently than do physicians of other disciplines.

The neurosurgical workforce in North America: a critical review of gender issues

OBJECTIVE

The role of women in Western society has changed dramatically in the past several decades. Despite this, many gender disparities still exist for professionals in the health care sector. In neurosurgery, a disproportionately small percentage of the workforce in the United States and Canada is female. These figures are lower than most reported in other medical specialties. This review critically examines factors that may be influencing women's ability to advance in demanding subspecialties such as neurosurgery.

METHODS

The literature on women in medicine, and surgery in particular, were reviewed to identify different issues facing women currently in practice in neurosurgery. In addition, the concerns of prospective trainees were examined.

RESULTS

There remain many challenges for women entering neurosurgery, including unique lifestyle concerns, limited mentorship, out-dated career programs, and deep-seeded societal beliefs. Discrimination and harassment are also contributing factors.

CONCLUSION

If neurosurgery is to continue to progress as a subspecialty, the issue of gender inequality needs to be scrutinized more closely. Innovative programs must be developed to meet the needs of current female faculty members and to ensure attracting the brightest individuals of both genders into a career in neurosurgery.

Factors influencing medical students' choice of specialty

BACKGROUND/PURPOSE

Medical school graduates are the source of a country's physicians. Determining how the graduates of these schools select their areas of specialization is the key to achieving a balanced distribution of doctors among all specialties. The purposes of this study were to determine the factors that influence medical students' choice of medical specialty, and to derive the relative weight of each factor.

METHODS

We constructed a two-tiered analytic hierarchy process (AHP) model which was represented in a questionnaire sent to 500 senior medical students to survey their opinions. The relative weight of each factor in the model was calculated. Analysis of variance and t test were applied to test for any significant differences in opinion among the students.

RESULTS

On the first tier of the AHP model, the aspect of "personal preferences and work achievement" had the highest weight of 0.460, followed by "specialty characteristics" with 0.291, and then the "specialty training process" with 0.249. Of the 14 criteria on the second tier, "personal intelligence/ability preference" had the highest weight of 0.197, followed by "career opportunities" with 0.107 and "lifestyle after completion of training" with 0.094.

CONCLUSION

This study found that personal intelligence/ability preference and career opportunities were more important factors to the current generation of students in choosing a specialty. Knowledge of these students' attitudes could form the basis for the development of strategies to enhance the attractiveness of specialties facing the problem of a shortage of manpower.

See one, do one, teach one: developing professionalism across the generations

Individuals develop their professional values and identity as they progress through the hierarchical career stages of medicine. At the same time, the collective values of the profession evolve with changes in the wider society. This leads to recurring small but significant generation gaps in professional values. For the past half century, this gap has centered on the concept of altruism and quality of life. In order for professionalism to develop at the individual level as well as for the community of physicians, the generational differences must be bridged and negotiations for change must build on common ground. This requires a long-term developmental approach including teaching strategies which are career stage appropriate and adapt to the different learning styles of the younger generation.

Clinical teaching and clinical outcomes: teaching capability and its association with patient outcomes

BACKGROUND

There is little research on the impact of medical education on patient outcome. We studied whether teaching capability is associated with altered short-term patient outcomes.

METHODS

We performed a multicentre retrospective cross-sectional study involving 40 clinician teachers who had attended on the general internal medicine services in hospitals affiliated with the University of Toronto along with the clinical outcomes of consecutive patients treated for community-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease and gastrointestinal bleeding (n = 4377) between 1999 and 2001. Doctors were characterised by teaching effectiveness scores (n = 677) as high-rated or low-rated according to house staff ratings.

RESULTS

There was no correlation between the teaching effectiveness scores and the mean length of stay for those patients treated for community-acquired pneumonia (high-rated = 10.3 versus low-rated = 8.1 days, P = 0.058), congestive heart failure (high-rated = 10.1 versus low-rated = 9.9 days, P = 0.978), chronic obstructive pulmonary disease (high-rated = 9.4 versus low-rated = 9.9 days, P = 0.419) and gastrointestinal bleeding (high-rated = 6.3 versus low-rated = 6.8 days, P = 0.741). In addition, we observed no significant correlation between teaching effectiveness scores and 7-day, 28-day and 1-year readmission rates for all pre-specified diagnoses.

CONCLUSION

There is no large correlation between teaching effectiveness scores and short-term patient outcomes, suggesting that doctor teaching capabilities, as perceived by house staff, does not generally impact clinical care.

Role modeling humanistic behavior: learning bedside manner from the experts

PURPOSE

Humanistic care is regarded as important by patients and professional accrediting agencies, but little is known about how attitudes and behaviors in this domain are taught in clinical settings. To answer this question, the authors studied how excellent clinical teachers impart the behaviors and attitudes consistent with humanistic care to their learners.

METHOD

Using an observational, qualitative methodology, the authors studied 12 clinical faculty identified by the medical residents enrolled from 2003 to 2004 as excellent teachers of humanistic care on the inpatient medical services at four medical universities in the United States (University of Minnesota Medical School, Emory University, University of Rochester School of Medicine, and Baylor College of Medicine). Observations were conducted by the authors using standardized field notes. After each encounter, the authors debriefed patients, learners (residents and medical students), and the teaching physicians in semistructured interviews.

RESULTS

Clinical teachers taught primarily by role modeling. Although they were highly aware of their significance as role models, they did not typically address the human dimensions of care overtly. Despite the common themes of role modeling identified, each clinical teacher exhibited unique teaching strategies. These clinical teachers identified self-reflection as the primary method by which they developed and refined their teaching strategies.

CONCLUSIONS

Role modeling is the primary method by which excellent clinical teachers try to teach medical residents humanistic aspects of medical care. Although clinical teachers develop unique teaching styles and strategies, common themes are shared and could be used for the future development of clinical faculty.

Quality of care for acute myocardial infarction in elderly patients with alcohol-related diagnoses

BACKGROUND

Elderly adults with alcohol-related diagnoses represent a vulnerable population that may receive lower quality of treatment during hospitalization for acute myocardial infarction. We sought to determine whether elderly patients with alcohol-related diagnoses are less likely to receive standard indicators of quality care for acute myocardial infarction.

METHODS

We conducted a retrospective cohort analysis using administrative and medical record data from the Cooperative Cardiovascular Project. Subjects were Medicare beneficiaries with a confirmed principal discharge diagnosis of acute myocardial infarction from all acute care hospitals in the United States over an 8-month period. Our primary outcome was the receipt of 7 guideline-recommended care measures among all eligible patients and patients who were ideal candidates for a given measure.

RESULTS

In all, 1,284 (1%) of the 155,026 eligible patients met criteria for an alcohol-related diagnosis. Among the alcohol-related diagnoses, 1,077/1,284 (84%) were for the diagnoses of alcohol dependence or alcohol abuse. Patients with alcohol-related diagnoses were less likely than those without alcohol-related diagnoses to receive beta-blockers at the time of discharge (55% vs. 60%, p = 0.02). We found no other significant differences in performance of the quality indicators after stratifying by indication and adjustment for baseline characteristics.

CONCLUSIONS

Alcohol-related diagnoses are not a barrier to receiving most quality of care measures in elderly patients hospitalized for acute myocardial infarction.

Effect of the inpatient general medicine rotation on student pursuit of a generalist career

BACKGROUND

Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain.

OBJECTIVE

To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM.

DESIGN

Multicenter cohort study.

PARTICIPANTS

Third-year medical students between July 2001 and June 2003.

MEASUREMENTS

End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of "Very Likely" or "Certain" to the question "How likely are you to pursue a career in GIM?"; and (2) entry into an internal medicine residency using institutional match data.

RESULTS

Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01).

CONCLUSIONS

Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.

Clinical role models are important in the early years of a problem-based learning curriculum

Following a comprehensive study of the role models identified by the first five years of students in a traditional medical programme, it was hypothesized that with curriculum reform clinical role models would assume greater importance earlier in the undergraduate medical programme. Indeed, when compared with their first- and second-year traditional curriculum colleagues, more problem-based learning students identified role models. Almost four times as many identified faculty role models (largely medically qualified) in comparison with their traditional curriculum counterparts. Concomitant with this increase was a decline in the selection by the PBL students of family members, friends and other students as role models. For all cohorts, however, the mother was the most important role model. Since students in integrated curricula have earlier clinical experience and patient contact, they interact with clinicians in hospitals and clinics as well as in the academic environment of the small-group tutorial and lecture theatres. Academic faculty members, particularly clinicians, need to be aware that students take note of their attitudes and behaviour as members of the medical profession, a profession that students had chosen as a career. Retraining of senior doctors from the traditional curriculum might be necessary to ensure that all clinicians have an equivalent understanding of patient care.

Economic factors and the percentage of residency positions filled by United States medical graduates

OBJECTIVE

To study the association between economic factors and the percentage of specialty residency positions filled by U.S. medical graduates.

METHODS

Data from the 2004 National Resident Matching Program were used to estimate the percentage of residency positions filled by U.S. medical graduates in 15 major specialties. Data from the Medical Group Management Association, American Medical Association, and a major Massachusetts liability insurer were used to estimate the mean and median physician income, work hours, and the relative cost of professional liability insurance.

RESULTS

The percentage of residency positions filled by United States medical graduates varied by specialty. In 2004, U.S. graduates filled more than 90% of the residency positions in orthopedics, plastic surgery, and neurosurgery. In contrast, U.S. graduates filled fewer than 60% of the residency positions in internal medicine and family medicine. A positive correlation between mean annual income and the percentage of residency positions filled by U.S. medical graduates (r = 0.78, P < .001) was observed across the 15 specialties studied. In a multivariate analysis, professional liability costs were not associated with the percentage of residency positions filled by U.S. graduates after controlling for annual income (P = .46).

CONCLUSION

Economic factors are associated with the percentage of specialty positions filled by U.S. medical graduates. Procedure-based and hospital-based specialties with an above-average annual income are most likely to have their residency positions filled by U.S. medical graduates.

LEVEL OF EVIDENCE

III.

Medical students' perceptions of resident teaching: have duty hours regulations had an impact?

OBJECTIVE

This study describes medical students' perceptions about resident teaching on a surgery clerkship and examines student perceptions before and after the implementation of duty hours regulations (DHR).

SUMMARY BACKGROUND DATA

There has been much discussion about the impact of DHR on surgical education. One area that merits evaluation is the effect that DHR have had on student education. Learners perceive the clinical teacher role as comprised of 4 roles: teacher, person, physician, and supervisor. This model served as the basis for examining resident teaching before and after DHR.

METHODS

Students completed end-of-rotation evaluations about residents' teaching effectiveness, amount of feedback, and quality of interactions. Student comments were compiled into individual resident reports, and reports were collected from pre- (2002-2003) and post- (2003-2004) DHR. A coding scheme was developed to describe resident performance in 4 roles: teacher, person, physician, and supervisor. Three coders independently reviewed 124 resident reports maintaining an interrater agreement of 80%. Analyses of variance were conducted to compare data from pre- and post-DHR.

RESULTS

After implementation of DHR, there were significantly more negative comments (P = 0.005), including comments about residents as supervisor (P = 0.001), teacher (P = 0.027), and teaching activities (P = 0.001). Positive comments about bedside teaching decreased (P = 0.007). Although total positive comments about resident as person increased (P = 0.01), total negative comments about resident as person also increased (P = 0.02).

CONCLUSIONS

Findings of this study indicate that DHR have had a negative impact on medical students' perceptions of resident teaching. Surgical educators must develop programs that address resident teaching skills in a different environment.

WHAT MAKES A MEDICAL STUDENT AVOID OR ENTER A CAREER IN UROLOGY? RESULTS OF AN INTERNATIONAL SURVEY

PURPOSE

To recruit the best and brightest medical students, it is crucial to understand what causes a medical student to pursue or avoid a career in urology. We performed a survey of 2 cohorts of residency applicants to elucidate these determinants.

MATERIALS AND METHODS

All 410 applicants to the 2003-2004 United States urology residency match and all 624 individuals who applied to a Boston-area emergency medicine (EM) residency program were invited to participate in the study. The on-line survey for the urology applicants asked the research question "What caused you to pursue the specialty of urology?" The EM applicant survey asked the research question "What caused you NOT to pursue a career in a surgical subspecialty, such as urology?" Qualitative responses were analyzed for themes by 2 researchers and independently coded.

RESULTS

Sixty percent (248 of 410) of urology applicants and 40% (252 of 624) of EM applicants completed the survey. Thematic coding of the qualitative responses yielded an inter-rater agreement of 89% to 94%. Positive determinants cited by urology applicants included the mix of medicine/surgery, the diversity of urological procedures, and clinical exposure to the field. Negative determinants cited by EM applicants included the narrowness of the specialty, an unattractive lifestyle, and the demands of a surgical residency. No significant correlations were noted between themes cited and participants' genders, degrees or medical school nationalities.

CONCLUSIONS

Ensuring that medical students have clinical exposure to urology, receive appropriate mentorship, and develop realistic perceptions of the specialty may substantially facilitate recruitment.

Why are women deterred from general surgery training?

BACKGROUND

This study explored the factors contributing to the low application rates to general surgery (GS) residency by female students and compared perceptions of GS between students and female surgeons.

METHODS

We distributed surveys to final-year students at 4 medical schools and nationwide to every female general surgeon in Canada.

RESULTS

Of students who were deterred from GS, women were less likely than men to meet a same-sex GS role model and more likely to experience gender-based discrimination during their GS rotation (P < .05). Female students had the perception that GS was incompatible with a rewarding family life, happy marriage, or having children, whereas female surgeons were far more positive about their career choice.

CONCLUSIONS

Both real and perceived barriers may deter women from a career in GS. Real barriers include sex-based discrimination and a lack of female role models in GS. There are also clear differences in perception between students and surgeons regarding family and lifestyle in GS that must be addressed.

An Internet-based survey of factors influencing medical student selection of a general surgery career

BACKGROUND

This study descriptively analyzes characteristics of general surgery residency and practice and their influence on student interest in surgical careers.

METHODS

Fourth-year medical students were invited to complete an Internet-based survey. A 5-point Likert scale described characteristics of general surgery residency and practice influencing medical student specialty selection. The same characteristics of nonsurgical careers were evaluated for students entering other specialties.

RESULTS

A convenience sample of 408 students from 16 medical schools completed the survey. All respondents viewed lifestyles of surgical residents and attending surgeons as negative influences on specialty selection. Workload during surgical residency negatively influenced all respondents' interest in a surgical career. Role model identification and perceived personality fit were important in selection of all specialties.

CONCLUSIONS

Medical students who choose surgical careers are not deterred by a negative perception of lifestyle and workload considerations. Mentoring and personality fit are central in medical student specialty selection.

A brief private group practice rotation changes junior medical students' perception of the surgical lifestyle

BACKGROUND

Surgical practice is often perceived by students as a stressful and demanding lifestyle in which personal and family issues take low priority. For students to receive a more balanced view of surgical practice, we instituted a private practice preceptorship during the last week of our junior surgery clerkship in 2001. We hypothesized that a 4-day preceptorship with surgeons in private practice would improve student perception of surgery as a valid career choice without compromising student educational performance.

METHODS

From January to December 2002, 107 junior medical students were assigned to a brief preceptorship with volunteer private practice surgeons during the surgery clerkship (group 1), while 28 students did not participate in the preceptorship (group 2). We assessed student satisfaction via questionnaire and compared student grade performance between groups.

RESULTS

One hundred two questionnaires (95%) were returned. Overall, the preceptor experience was rated positively (9.0+/-0.1) based on a 10-point Likert scale. All students commented on the educational or enjoyment value of the preceptorship, with 44% specifically stating that the lifestyle in private surgical practice appeared pleasant. Interestingly, 9% of students volunteered that the experience had swayed them to consider surgery as a career. Twenty-four percent of questionnaires contained negative comments, mainly concerning not enough "hands-on" participation. Grades for the clerkship did not decrease in group 1 when compared with group 2 or with historic controls (n=113).

CONCLUSIONS

A 4-day private practice preceptorship at the end of the junior surgery clerkship favorably alters student perceptions of a surgical career without diminishing student grade performance.

Teaching residents how to teach improves quality of clerkship

OBJECTIVE

To evaluate the impact of a resident's teaching skills workshop on the ratings of the obstetrics and gynecology clerkship by third-year medical students.

STUDY DESIGN

The 6-week obstetrics and gynecology clerkship at the University of Michigan is provided at 4 different sites including the University of Michigan Hospital. At the end of each rotation, medical students complete an evaluation form assessing various aspects of their learning experience, including the overall quality of clerkship. A workshop, "Teaching Residents How to Teach," was conducted at the University of Michigan Hospital, whereas the other 3 sites served as the control. Clerkship evaluations were compared before and after the workshop using Student t test.

RESULTS

Students at the University of Michigan Hospital rated all items on the evaluation form higher after the teaching workshop. The overall quality of the clerkship at the University of Michigan Hospital improved ( P = .05), whereas the other sites remained stable.

CONCLUSIONS

A "Teaching the Residents How to Teach" workshop improves the overall quality of the clerkship.

Why don’t female medical students choose diagnostic radiology? A review of the current literature

While the number of women entering medical schools is approaching 50% nationally, women continue to be underrepresented in a number of specialties including diagnostic radiology. While diagnostic radiology has many characteristics that might be desirable to women, such as reasonable call hours, flexible scheduling, and high salaries, women still do not choose diagnostic radiology as a career. This article examines the literature to discern possible reasons for why women are entering diagnostic radiology at a lower rate. We address trends among women in academic medicine, which resemble trends among women in diagnostic radiology, and examine the effects of gender and socialization in medical school on specialty choices among women. The current literature suggests a constellation of factors may be responsible for the gender differences in diagnostic radiology. We suggest that further research is needed to elucidate why women do not seem to be choosing diagnostic radiology as frequently as one might predict based on the lifestyle of diagnostic radiologists and the numbers of women currently entering medical school. Once these reasons are made clear, it will be possible for residency program directors and medical schools to ensure that women are making informed specialty choices, whatever those choices may be.

How medical students define surgical mentors

BACKGROUND

Current literature does not define ideal qualities of surgical mentors. We sought to define mentoring qualities desired by medical students in attending and resident surgeons.

METHODS

We conducted a survey asking third-year medical students to identify the best attending surgeon and resident surgeon mentors during their surgical clerkship and to explain their selections. Comments were systematically evaluated using content analysis.

RESULTS

The survey response rate was 94.8%. Attending surgeon mentors were described by 84 students; 70 students described resident surgeon mentors. Students most frequently described the "teacher" role for attending surgeons. For resident surgeon mentors, students most often ranked the "person" role. Students prioritized characteristics or attributes within roles differently for attending and resident surgeon mentors.

CONCLUSIONS

Medical students' expectations of attending and resident surgeon mentors differ. Emphasis on behaviors consonant with identified characteristics may improve mentoring of medical students by surgeons and increase interest in surgical careers.

Role modeling in physicians' professional formation: reconsidering an essential but untapped educational strategy

Forming technically proficient, professional, and humanistic physicians for the 21st century is no easy task. Mountains of biomedical knowledge must be acquired, diagnostic competence achieved, effective communication skills developed, and a solid and applicable understanding of the practice and role of physicians in society today must be reached. The central experience for learners in this complex and challenging terrain is the "modeling of" and "learning how to be" a caregiver and health professional. Role modeling remains one crucial area where standards are elusive and where repeated negative learning experiences may adversely impact the development of professionalism in medical students and residents. The literature is mainly descriptive, defining the attributes of good role models from both learners and practitioners' perspectives. Because physicians are not "playing a role" as an actor might, but "embodying" different types of roles, the cognitive and behavioral processes associated with successfully internalizing roles (e.g., the good doctor/medical educator) are important. In this article, the authors identify foundational questions regarding role models and professional character formation; describe major social and historical reasons for inattention to character formation in new physicians; draw insights about this important area from ethics and education theory (philosophical inquiry, apprenticeship, situated learning, observational learning, reflective practice); and suggest the practical consequences of this work for faculty recruitment, affirmation, and development.

Gender awareness among physicians--the effect of specialty and gender. A study of teachers at a Swedish medical school

BACKGROUND

An important goal for medical education today is professional development including gender equality and awareness of gender issues. Are medical teachers prepared for this task? We investigated gender awareness among physician teachers, expressed as their attitudes towards the role of gender in professional relationships, and how it varied with physician gender and specialty. We discuss how this might be related to the gender climate and sex segregation in different specialties.

METHOD

Questionnaires were sent to all 468 specialists in the clinical departments and in family medicine, who were engaged in educating medical students at a Swedish university. They were asked to rate, on visual analogue scales, the importance of physician and patient gender in consultation, of preceptor and student gender in clinical tutoring and of physician gender in other professional encounters. Differences between family physicians, surgical, and non-surgical hospital doctors, and between women and men were estimated by chi-2 tests and multivariate logistic regression analyses.

RESULTS

The response rate was 65 %. There were differences between specialty groups in all investigated areas mainly due to disparities among men. The odds for a male family physician to assess gender important were three times higher, and for a male non-surgical doctor two times higher when compared to a male surgical doctor. Female teachers assessed gender important to a higher degree than men. Among women there were no significant differences between specialty groups.

CONCLUSIONS

There was an interaction between physician teachers' gender and specialty as to whether they identified gender as important in professional relationships. Male physicians, especially from the surgical group, assessed gender important to a significantly lower degree than female physicians. Physicians' degree of gender awareness may, as one of many factors, affect working climate and the distribution of women and men in different specialties. Therefore, to improve working climate and reduce segregation we suggest efforts to increase gender awareness among physicians, for example educational programs where continuous reflections about gender attitudes are encouraged.

Are there gender differences in choosing a surgical career?

BACKGROUND

Interest in general surgery has declined among US medical students, with the increasing number of female medical students being cited as a causative factor. This study evaluates factors related to choosing a general surgery career and determines if they differ between men and women.

METHODS

A survey assessing factors that contributed to career choice was distributed to a 2002 graduating medical school class to be returned with their match lists. Students were asked, from a given list, which factors influenced their career choice. Those students who did not pursue a career in general surgery were asked what factors contributed to that decision. The results were stratified by gender.

RESULTS

Of 120 surveys, 54 women and 48 men responded (response rate=85%). The reason most commonly cited for a particular career choice by both men and women was the intellectual challenge of the field, chosen by 41 men (85%) and 46 women (85%). The two next most common reasons cited by male students were an elective in the field and practice lifestyle (40 of 48 respondents, or 82%, for each). Practice lifestyle was a contributing factor for 37 of the 54 women, or 69% (P=.132). The other reasons most commonly cited by women were an elective and faculty in the chosen field (46 of 54, or 85%, and 38 of 54, or 70%). Thirty-seven of the 48 men, or 77% (P=.588), felt that faculty in the field contributed to their career choice. The most commonly cited reasons for not choosing general surgery--residency lifestyle, practice lifestyle, and length of training--were the same for both groups.

CONCLUSIONS

Fewer women than men considered practice lifestyle in choosing their medical career. However, both men and women considered lifestyle, elective in the field of choice, and faculty important in career choice. In 2002, men and women had the same reasons for pursuing a career in general surgery or seeking another specialty.

Does a general surgery clerkship influence student perceptions of surgeons and surgical careers?

BACKGROUND

Student perceptions of surgeons and surgical careers may influence their decision to pursue a surgical career. We evaluated the impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers and of the clerkship on student interest in surgical careers.

METHODS

We conducted voluntary pre- and postclerkship surveys of third-year medical students who were enrolled in their required general surgery clerkship and used 5-point Likert scale rankings to capture agreement with declarative statements (1 = strongly agree; 5 = strongly disagree). T-tests were used to evaluate both paired and individual items.

RESULTS

Students indicated that their surgical clerkship improved their opinion of surgeons (2.47; P <.001). Several perceptions changed after the clerkship. First, students agreed more strongly that surgeons were compassionate physicians (ranking, 2.87 vs 2.53; P =.003) and that patients respected surgeons (ranking, 1.84 vs 1.62; P =.026). Acknowledgment of career satisfaction by students increased (ranking, 2.57 vs 2.22; P =.008). Students more strongly disagreed that "surgeons [were] respectful of other physicians" (ranking, 3.29 vs 3.62; P =.009). Interest in surgical careers did not change significantly during the clerkship (ranking, 2.83 vs 2.68; P =.218).

CONCLUSIONS

Medical student perceptions of surgeons and surgical careers generally improve during the surgical clerkship. However, student impressions of surgeons' collegial behavior and commitment to teaching deteriorate significantly during the surgical clerkship.

Serving as a physician role model for a diverse population of medical learners

PURPOSE

Medical learners look to role models to better understand the values, attitudes, behaviors, and ethics of the medical profession. This study examined issues related to physicians serving as role models for diverse medical learners.

METHOD

Between September and November 2000, in-depth semi-structured 30-minute interviews were conducted with 29 highly regarded role models, as judged by medical house officers at two large teaching hospitals in Baltimore, Maryland. Interview transcripts were independently coded and compared for agreement. Content analysis identified several major categories of themes that were examined and conceptually organized.

RESULTS

The informants identified issues that relate to role modeling for diverse medical learners. Subcategories under the domain of similarity facilitates role modeling included learners prefer role models similar to them, role modeling is easier when the learner resembles the teacher, and minority physicians may be better role models for minority learners. Under the domain role modeling when physician-teachers and learners are different were the subcategories extra effort may be necessary, success promotes and inspires confidence, and role modeling across diversity is an achievable objective that should be pursued. The final domain, approaches to differences between physician-teachers and learners, encompassed embrace diversity, act as a consultant and refer when necessary, and minimize and disregard all differences.

CONCLUSIONS

The results of this study should draw attention to these issues and may serve as a stimulus for teaching physicians to consider a broader range of options for successful interactions with medical learners who are different from them.

Variation in predictors of primary care career choice by year and stage of training

CONTEXT

It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education.

OBJECTIVE

To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training.

DESIGN

A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997.

PARTICIPANTS

A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were re-interviewed as third-year residents in 1997.

MAIN OUTCOME MEASURE

Primary care (general internal medicine, general pediatrics, or family medicine) career choice.

RESULTS

Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training.

CONCLUSIONS

The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

Feedback and reflection: teaching methods for clinical settings

Feedback and reflection are two basic teaching methods used in clinical settings. In this article, the authors explore the distinctions between, and the potential impact of, feedback and reflection in clinical teaching. Feedback is the heart of medical education; different teaching encounters call for different types of feedback. Although most clinicians are familiar with the principles of giving feedback, many clinicians probably do not recognize the many opportunities presented to them for using feedback as a teaching tool. Reflection in medicine-the consideration of the larger context, the meaning, and the implications of an experience and action-allows the assimilation and reordering of concepts, skills, knowledge, and values into pre-existing knowledge structures. When used well, reflection will promote the growth of the individual. While feedback is not used often enough, reflection is probably used even less.