Do students' attitudes during preclinical years predict their humanism as clerkship students?

Diseño e implementación del modelo de humanización integral en salud de la Facultad de Medicina de la Universidad Nacional de Colombia

El objetivo de este artículo es describir las bases y generalidades del proceso de diseño e implementación del modelo de humanización integral en salud de la Facultad de Medicina de la Universidad Nacional de Colombia, el cual empezó a desarrollarse en en 2016 y que en la actualidad también se ha implementado en el Hospital Universitario Nacional (HUN). Con este modelo, el Grupo de Investigación en Humanización en Salud de la Facultad de Medicina busca generar un cambio cultural en la percepción de la humanización de la salud en el país, de la formación de los profesionales de la salud, de la prestación de atención en salud y de las condiciones laborales del personal de salud, a partir de una aproximación biopsicosocial. El modelo se fundamenta en tres ejes: la humanización en la atención en salud, enfocada en el paciente, la familia y los cuidadores; la humanización en los procesos de educación en ciencias de la salud, con énfasis en los estudiantes, y la humanización en la calidad de vida y las condiciones laborales de los profesionales de la salud. Así mismo, el modelo considera a la formación humanística, la música y el deporte como medios para lograr dicho cambio cultural en la Facultad de Medicina de la Universidad Nacional de Colombia.

Role of community health service programs in navigating the medical ethical slippery slope-a 10-year retrospective study among medical students from southern China

BACKGROUND

For promoting autonomous learning motivation, the learning effect of community-oriented service is beneficial, because through community participation and service, students can transfer their implicit cognition of ethics into explicit cognition, leading to the cultivation of a sympathetic partnership between the community and medical students. Despite the proven benefits of medical students' community health service (CHS) in Western countries, CHS programs designed for medical students are not well established in mainland China, and their effects on medical students' ethical cognition are largely unknown. This study evaluated the effects of CHS programs on the ethical cognition of medical students.

METHODS

A cross-sectional study was conducted on third- and fourth-year medical students and graduates working at Shantou University Medical College by using a self-administered anonymous questionnaire. Through interviews, we applied a thematic approach to analyze the responses of the participating students. The questionnaire adopted in this study was revised based on a review of the literature on medical ethics in medical students and on the CHS environment in China. The reviewed questionnaires included an evaluation questionnaire on cultivating medical ethics in a CHS context, and questionnaires used to explore the cultivation and transformation of medical ethics in medical students during the preclinical period.

RESULTS

A total of 361 (54.4%) undergraduate medical students and 302 (45.6%) graduates participated in this survey. Significant differences were observed in self-evaluation of the cognitive development of ethics between those who had participated in CHS programs 1-5 times and those who had participated > 6 times. The successful identification of accepting money from the patients under the table as unethical behavior significantly differed (p = .031) among the graduates but not (p = .567) among the undergraduate students. The participants expressed the positive impact of CHS programs on their self-development.

CONCLUSION

CHS programs can be widely applied in medical education in China. This educational strategy, which supports medical professionalism and incorporates humanitarian behavior as a complement to learning, should be encouraged and promoted nationally.

Considering axiological integrity: a methodological analysis of qualitative evidence syntheses, and its implications for health professions education

Qualitative evidence synthesis (QES) is a suite of methodologies that combine qualitative techniques with the synthesis of qualitative knowledge. They are particularly suited to medical education as these approaches pool findings from original qualitative studies, whilst paying attention to context and theoretical development. Although increasingly sophisticated use is being made of qualitative primary research methodologies in health professions education (HPE) the use of secondary qualitative reviews in HPE remains underdeveloped. This study examined QES methods applied to clinical humanism in healthcare as a way of advancing thinking around the use of QES in HPE in general. A systematic search strategy identified 49 reviews that fulfilled the inclusion criteria. Meta-study was used to develop an analytic summary of methodological characteristics, the role of theory, and the synthetic processes used in QES reviews. Fifteen reviews used a defined methodology, and 17 clearly explained the processes that led from data extraction to synthesis. Eight reviews adopted a specific theoretical perspective. Authors rarely described their reflexive relationship with their data. Epistemological positions tended to be implied rather than explicit. Twenty-five reviews included some form of quality appraisal, although it was often unclear how authors acted on its results. Reviewers under-reported qualitative approaches in their review methodologies, and tended to focus on elements such as systematicity and checklist quality appraisal that were more germane to quantitative evidence synthesis. A core concern was that the axiological (value) dimensions of the source materials were rarely considered let alone accommodated in the synthesis techniques used. QES can be used in HPE research but only with careful attention to maintaining axiological integrity.

Attitudes of medical students toward communication skills learning in Western Saudi Arabia

Objectives:

To explore medical students’ attitudes towards communication skills learning in Western Saudi Arabia and to examine impact of socio-demographic variables on the attitudes towards learning these skills.

Methods:

In this cross-sectional study, sample of medical students were recruited from Taif University, Taif, Kingdom of Saudi Arabia during the second semester (January-May 2014). Participants were all year 2 (197 students) and year 5 (151 students). The study utilize the Communication Skills Attitude Scale (CSAS) to measure students’ attitudes toward communication skills learning. The response rate was 93.9%.

Results:

The study showed that Taif medical students hold highly positive attitudes towards learning communication skills. Positive attitude score (PAS) was significantly higher in level 5 students, older age group.

Conclusion:

Significant positive attitude toward learning communication skills clearly observed in target group. Students with more positive attitudes towards communication skills learning tended to be higher level and older age.

A psychometric evaluation of the Gender Bias in Medical Education Scale

BACKGROUND

Gender bias within medical education is gaining increasing attention. However, valid and reliable measures are needed to adequately address and monitor this issue. This research conducts a psychometric evaluation of a short multidimensional scale that assesses medical students' awareness of gender bias, beliefs that gender bias should be addressed, and experience of gender bias during medical education.

METHODS

Using students from the University of Wollongong, one pilot study and two empirical studies were conducted. The pilot study was used to scope the domain space (n = 28). This initial measure was extended to develop the Gender Bias in Medical Education Scale (GBMES). For Study 1 (n = 172), confirmatory factor analysis assessed the construct validity of the three-factor structure (awareness, beliefs, experience) and enabled deletion of redundant items. Study 2 (n = 457) tested the generalizability of the refined scale to a new sample. Combining Study 1 and 2, invariance testing for program of study and gender was explored. The relationship of the GBMES to demographic and gender politics variables was tested. The results were analyzed in R using confirmatory factor analysis and Multiple-Indicator-Multiple-Indicator-Cause models.

RESULTS

After analysis of the responses from the original 16-item GBMES (Study 1), a shortened measure of ten items fitted the data well (RMSEA = .063; CFI = .965; TLI = .951; Mean R-square of items = 58.6 %; reliability: .720-.910) and was found to generalize to a new sample in Study 2 (RMSEA = .068; CFI = .952; TLI = .933; Mean R-square of items = 55.9 %; reliability: .711-.892). The GBMES was found to be invariant across studies, gender, and program of study. Female students and those who supported gender equality had greater agreement for each of the factors. Likewise, postgraduate students reported higher scores on experience of gender bias than undergraduate students.

CONCLUSION

The GBMES provides a validated short multidimensional measure for use in research and policy. Given its good reliability across different target populations and its concise length, the GBMES has much potential for application in research and education to assess students' attitudes towards gender bias.

Medical students' attitudes toward people with dementia: an international investigation

BACKGROUND

The changing demographics of societies mean that medical students worldwide must be sufficiently prepared to care competently for patients with dementia through development of appropriate knowledge, skills, and attitudes. No previous research had explored undergraduate medical students' attitudes toward people with dementia.

METHODS

An adapted version of the Approaches to Dementia Questionnaire (ADQ) was completed by 501 medical undergraduates in years 1, 3, and 5 of their degree programs in the UK and Malaysia. Non-parametric statistical analysis focused on any differences between year groups and geographical locations.

RESULTS

The mean ADQ response indicated a generally positive attitude across the sample, comparable with other healthcare professionals previously surveyed. Year 3 and year 5 students expressed significantly more positive attitudes than year 1 students. Year 1 students based in the UK expressed significantly more positive attitudes than year 1 student based in Malaysia, but there were no significant differences between year 3 students based in different locations.

CONCLUSION

The more positive attitudes found amongst year 3 and year 5 students compared to year 1 may be a result of teaching emphasizing a person-centered approach. The differences between entry-level students from Malaysia and the UK may reflect variance in cultural norms and expectations, or the ADQ's "Western" origin. Medical schools aiming to equip students with dementia-specific skills and knowledge can draw on the generally positive attitudes found in this study.

Medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships

OBJECTIVE

Literature indicates a decline in patient-centredness in medical students, especially during clinical clerkships. We examined the impact of preclinical communication skills training (CST) on students' development of patient-centred attitudes and attitudes toward CST during clerkships.

METHODS

We prospectively compared two cohorts before and after clerkships: one cohort (n=48) had not received CST, whereas the other (n=37) had received a five-year CST. We assessed the impact using five validated questionnaires.

RESULTS

Communication trained students slightly but significantly declined in patient-centred attitudes (3/4 scales) and attitudes toward CST during clerkships, whereas the scores of the untrained students remained stable (5/5 scales). Both cohorts did not differ in attitudes before clerkships. In the trained cohort, males mostly showed a sharper decline than females. In the total group (n=85), females demonstrated higher attitude scores toward CST, and in 1/4 scales measuring patient-centred attitudes.

CONCLUSION

This cohort study suggests that CST might make students more vulnerable to decline in attitude scores during clerkships.

PRACTICE IMPLICATIONS

These remarkable findings, contrary to what educators would expect to result from their efforts, challenge medical education to address the new questions that are raised about the validity of the questionnaires, the impact of CST and the learning processes involved in the development of patient-centredness.

'Is that normal?' Pre-clerkship students' approaches to professional dilemmas

OBJECTIVES

Context has been recognised as a key variable in studies of medical student professionalism, yet the effect of students' stage of training has not been well explored, despite growing recognition that medical students begin to form their professional ethos from their earliest medical school experiences. The purpose of this study, which builds on previous research involving clinical clerks, was to explore the decision-making processes of pre-clerkship medical students in the face of standardised professional dilemmas.

METHODS

Structured interviews were conducted with 30 pre-clerkship (Years 1 and 2) medical students at one institution. During the interviews, students were asked to respond to five videotaped scenarios, each of which depicted a student facing a professional dilemma. Transcripts were analysed using an existing theoretical framework based on a constructivist grounded theory approach.

RESULTS

Pre-clerkship students' approaches to professional dilemmas were largely similar to those of clerks, despite their limited clinical experience, with several notable exceptions. For example, reliance on instincts and emotions was not as pervasive, but concerns with systems-associated issues were more recurrent. These findings were explored in the context of theory on professional identity formation.

CONCLUSIONS

As the novice student constructs a professional identity, he or she may feel the need to take on the role of doctor and shed that of student, a process that involves the suppressing of emotions, but this may be misguided. Educators should be aware of these stages of identity formation and tailor their teaching and evaluation of professionalism accordingly.

Professionalism beyond medical school: an educational continuum?

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.

Approaches to professional behaviour assessment: tools in the professionalism toolbox

There is general agreement that professionalism and professional behaviour should be (formatively and summatively) assessed, but consensus on how this should be done is still lacking. After discussing some of the remaining issues and questions regarding professionalism assessment, this article discusses the importance of qualitative comments to the assessment of professional behaviour, focuses on the currently most frequently used tools, as well as stresses the need for triangulation (combining) of these tools.

General considerations regarding assessment of professional behaviour

Core medical knowledge has been assessed for over fifty years and technical and communication skills for at least twenty. The assessment of professionalism however has failed to achieve recognition within this time frame. The interest in the assessment of professionalism and professional behaviour thus is a fairly recent development. This article will firstly clarify how professional behaviour assessment relates to other assessment methods using the framework proposed by Miller6. Thereafter a brief overview will be provided of the current "tool box" of methods available to assess professionalism. Data on the validity, reliability, feasibility, acceptability and educational utility of these "tools" as derived from published evidence will be reviewed. Subsequently a general overview of the way forward in the assessment of professionalism and professional behaviour will be given.

Capturing medical students' idealism

PURPOSE

Students' idealism and desire to work with underserved populations decline as they progress from preclinical training through clerkships and residency. With an increasingly diverse population and increasing health disparities, academic health centers need to incorporate changes in their curricula to train socially responsible and idealistic physicians. International electives can provide valuable learning experiences to help achieve these goals.

METHODS

Sixty-six preclinical medical students at the University of Texas Medical Branch participated in an international elective from 1997 to 2005. After 1 week of didactics, they spent 3 weeks as part of a multidisciplinary medical team in rural Nicaragua. Postelective questionnaires were administered. From students' responses, we identified common learning themes and grouped them under the categories of attitudes, awareness, and skills. Limitations included a self-selection bias, lack of a control group, and limited follow-up.

RESULTS

After the elective, students had an increased interest in volunteerism, humanitarian efforts, and working with underserved populations both in the United States and abroad, as well as more compassion toward the underserved. Students also reported a heightened awareness of social determinants of health and public health, and a broadened global perspective, as well as increased self-awareness.

CONCLUSIONS

Our findings illustrate that a well-structured, mentored experience in international health can have a positive impact on preclinical students' attitudes, including their compassion, volunteerism, and interest in serving under-served populations, all measures of idealism.

Fostering professionalism in medical education: a call for improved assessment and meaningful incentives

Increasing attention has been focused on developing professionalism in medical school graduates. Unfortunately, the culture of academic medical centers and the behaviors that faculty model are often incongruent with our image of professionalism. The need for improved role modeling, better assessment of student behavior, and focused faculty development is reviewed. We propose that the incentive structure be adjusted to reward professional behavior in both students and faculty. The third-year medicine clerkship provides an ideal opportunity for clinician-educators to play a leading role in evaluating, rewarding, and ultimately fostering professionalism in medical school graduates.

Attitude change during medical school: a cohort study

BACKGROUND

Attitudes influence behaviour. Developing and maintaining proper attitudes by medical students can impact on the quality of health care delivered to their patients as they assume the role of doctors. There is a paucity of longitudinal research reports on the extent to which students' attitude scores shift as they progress through medical school.

OBJECTIVE

This study examined the change in attitude scores of a large student cohort as they progressed through medical school. Whether student gender is related to attitude change was also investigated.

METHOD

Medical students from 3 consecutive classes (1999-2001) participated in this study. Students completed 2 instruments that included the Attitudes Toward Social Issues in Medicine and an in-house tool referred to as the Medical Skills Questionnaire. The instruments were administered at 3 milestones during the course of medical school training (entry, end of preclinical training and end of clerkship).

RESULTS

Reliability estimates for total (0.82-0.91) and subscale (0.41-0.81) attitudinal scores were in the acceptable range. Multivariate analyses of variance of mean attitudinal scores indicated a persistent decline in several attitude scores as students progressed through the medical educational programme. Females demonstrated higher attitude scores than males.

CONCLUSIONS

As students progress through medical school their attitude scores decline. The reasons for the shift in attitude scores are not clear but they may relate to a ceiling of high attitude scores at entry, loss of idealism and the impact of the unintended curriculum. Further study of the impact of medical education on student attitudes is warranted.

A Comparison of Humanistic Qualities Among Medical Students, Residents, and Faculty Physicians in Internal Medicine

Humanistic qualities of integrity, respect and compassion are important components of medical education. Studies, however, suggest that students may not perceive their faculty physicians as humanistic. Knowing how the perception of humanistic qualities varies by training level may offer insight on how we teach humanism. In this study, the authors compared humanistic quality scores of fourth-year medical students, internal medicine residents, and attending physicians on a general medicine ward of a teaching hospital. A validated nursing survey to assess humanistic qualities among physicians was distributed to randomly selected nurses on the medicine wards. The survey measured physician relationships with other medical staff, the patient, and family members. Each item was scored on a 5-point Likert scale. Composite scores for physician to staff relationships and physician to patient/family relationships, as well as an overall evaluation score, were compared across levels of physician training. A t test was done to determine statistical significance across training levels. No statistically significant differences were found between internal medicine residents and attending physicians. Subinterns appear to have better perceived qualities of humanism compared with resident and attending physicians. Because resident and attending physicians play an important role in medical education, efforts should be made to improve the perceived humanistic qualities of both resident and attending physicians.