Six ways problem-based learning cases can sabotage patient-centered medical education

When the Patient is Absent in Patient-Centered Communication Training: A Discursive Analysis of How Medical Students Learn to Interact with Patients

Phenomenon: Patient-centered communication is an ideal for undergraduate medical education and has been for decades. However, medical students often find the patient-centered approach challenging. The present study finds a possible discordance between formal intentions of a medical curriculum and the corresponding learning environment. The objective of our study was to explore how medical curriculum resonates with the purpose of patient-centered medicine, including how a possible dynamic may have helped maintain this discordance in undergraduate medical education. Approach: The study took a qualitative approach exploring the medical curriculum via a structured communication course. The educational context for the course was considered a discursive environment, partially constructed through documents. The concept of textual agency was used to analyze curriculum and course documents. This was to explore how competencies were presented in the medical curriculum and course descriptions and how they were translated through the practices of the communication course. Inductive thematic analysis was used to analyze observations made during the course. Findings: Our analysis suggested that the medical curriculum content and structure still emphasize bio-medical disciplines and knowledge domains in students learning. This connected well with the socialization of medical students toward the role as medical experts whose primary task is to provide information, while patients are defined as passive subjects, who received information. The course description also operationalized complexities of patient-centered communication to a measurable, instrumental structure of skills. This focus on one-directional communication frames the students' understanding of the courses and their performance in it. They learn that: (1) meeting a real patient is a rare opportunity, (2) engaging patients' thoughts and feelings in the conversation is challenging, and (3) the biomedical aspect should be prioritized in the conversation. Insights: These findings suggested that the medical curriculum we studied gave limited room for patient-centered medicine, even in communication training. The power of macro-level documents framed and focused micro-level learning activities and could help explain observed disharmonies in patient-medical student encounters. We see how patient-centered medicine - in both texts and practice - is represented and enacted as a peripheral activity and patients are given a marginal position in encounters with students. The findings suggested that there are challenges for progress and change toward a more patient-centered communication training and curriculum. However, empirical findings also offered points of departure for course leaders and curriculum planners wishing to take steps toward a stronger and more reflective patient-centered approach in medical education, supported through the document structure and the translation of the curriculum through relevant learning activities.

A meta-study analysing the discourses of discourse analysis in health professions education

INTRODUCTION

Discourse analysis has been used as an approach to conducting research in health professions education (HPE) for many years. However, because there is no one 'right' interpretation of or approach to it, quite what discourse analysis is, how it could or should be used, and how it can be appraised are unclear. This ambiguity risks undermining the trustworthiness and coherence of the methodology and any findings it produces.

METHOD

A meta-study review was conducted to explore the current state of discourse analysis in HPE, to guide researchers engaging using the methodology and to improving methodological, analytical and reporting rigour. Structured searches were conducted, returns were filtered for inclusion and 124 articles critically analysed.

RESULTS

Of 124 included articles, 64 were from medical education, 51 from nursing and 9 were mutli-disciplinary or from other HPE disciplines. Of 119 articles reporting some sort of data, 50 used documents/written text as the sole data source, while 27 were solely based on interview data. Foucault was the most commonly cited theorist (n = 47), particularly in medical education articles. The quality of articles varied: many did not provide a clear articulation what was meant by discourse, definitions and methodological choices were often misaligned, there was a lack of detail regarding data collection and analysis, and positionality statements and critiques were often underdeveloped or absent.

DISCUSSION

Seeking to address these many lacunae, the authors present a framework to facilitate rigorous discourse analysis research and transparent, complete and accurate reporting of the same, to help readers assess the trustworthiness of the findings from discourse analysis in HPE. Scholars are encouraged to reflect more deeply on the applications and practices of discourse analysis, with the ultimate aim of ensuring more breadth and depth when using discourse analysis for understanding and constructing meaning in our field.

A gender biased hidden curriculum of clinical vignettes in undergraduate medical training

OBJECTIVES

Medical education relies extensively on clinical vignettes, yet little attention has been given to what hidden curriculum they might convey. Our research aimed to identify whether the clinical vignettes used in pre-graduate medical education transmit gender stereotypes or gender biases.

METHODS

We conducted a mixed quantitative and qualitative analysis of gender-related characteristics currently existing in clinical vignettes used for pre-graduate teaching and evaluation at the Geneva Faculty of Medicine.

RESULTS

2359 vignettes were identified, of which 955 met inclusion criteria. Patients' professions and family caregiver roles showed a strongly gendered distribution, as did the healthcare professions where male physicians and female nurses were the norm. Qualitative results identified widespread stereotyped gender roles and gender expression.

CONCLUSION

Our study reveals that the clinical vignettes used in education and evaluation materials in pre-graduate medical education in Geneva convey a gender-biased hidden curriculum, which could negatively impact patient care and undermine equal opportunity for men and women.

PRACTICE IMPLICATIONS

Active revision of the content and the form of clinical vignettes used in undergraduate medical education is needed using a gender lens. Based on rare gender neutral or gender transformative examples from our study, we propose guidelines for writing non-gender-biased vignettes.

Exposing the disability-related hidden curriculum in case-based learning: A qualitative study

BACKGROUND

People with disabilities face significant health disparities. Studies show that healthcare professionals harbor negative attitudes towards disability, compromising the quality of care. These attitudes, in unwritten, unofficial, and even unintended ways can be passed from providers to learners in the medical education setting.

OBJECTIVE

Using a Critical Disability Studies (CDS) paradigm, the authors uncovered the disability-related hidden curriculum within Case-Based Learning (CBL) and proposed guidelines for promoting a disability-conscious medical education that resists ableism.

METHODS

The study team conducted a qualitative analysis of all CBL cases from the pre-clerkship curriculum (n = 53) at Sidney Kimmel Medical College. The authors employed a directed content analysis approach to develop a codebook based on case examination, literature review, and CDS concepts. Two researchers coded all cases and assessed intercoder reliability. The results informed the development of an explanatory model.

RESULTS

Only four of 53 cases overtly mentioned disability, none of which defined disability according to CDS. Coding did not identify content challenging stereotypical views of disability. Additionally, two cases included content fueling negative attitudes of disability.

CONCLUSION

By inadequately addressing disability from a CDS perspective, harmful assumptions of disability may go unchallenged, driving a hidden curriculum within CBL. This phenomenon leaves medical students ill-prepared to care for people with disabilities and creates physicians ill-equipped to teach the next generation. Since many health professions utilize CBL to educate students, these cases provide an untapped opportunity to resist ableism and better prepare students to address the negative attitudes driving health disparities experienced by people with disabilities.

Challenges facing standardised patients representing equity-deserving groups: Insights from health care educators

INTRODUCTION

Health professions training programmes increasingly rely on standardised patient (SP) programmes to integrate equity-deserving groups into learning and assessment opportunities. However, little is known about the optimal approach, and many SP programmes struggle to meet these growing needs. This study explored insights from health care educators working with SP programmes to deliver curricular content around equity-deserving groups.

METHODS

We interviewed 14 key informants in 2021 who were involved in creating or managing SP-based education. Verbatim transcripts were analysed in an iterative coding process, anchored by qualitative content analysis methodology and informed by two theoretical frameworks: sociologic translation and simulation design. Repeated cycles of data collection and analyses continued until themes could be constructed, aligned with existing theories and grounded in empirical data, with sufficient relevance and robustness to inform educators and curricular leads.

RESULTS

Three themes were constructed: (i) creating safety for SPs paid to be vulnerable, (ii) fidelity as an issue broader than who plays the role and (iii) engaging equity-deserving groups. SP work involving traditionally marginalised groups risk re-traumatization, highlighting the importance of (i) informed consent in recruiting SPs, (ii) separating role portrayal from lived experiences, (iii) adequately preparing learners and facilitators, (iv) creating time-outs and escapes for SPs and (v) building opportunity for de-roling with community support.

CONCLUSIONS

SP programmes are well positioned to be allies and advocates to equity-deserving groups and to collaborate and share governance of the educational development process from its outset. SP programmes can support the delivery of curricular content around equity-deserving groups by advocating with curricular leadership, building relationships with community partners, facilitating co-creation and co-delivery of educational content and building safety into simulation.

Case-Informed Learning in Medical Education: A Call for Ontological Fidelity

Case-informed learning is an umbrella term we use to classify pedagogical approaches that use text-based cases for learning. Examples include Problem-Based, Case-Based, and Team-Based approaches, amongst others. We contend that the cases at the heart of case-informed learning are philosophical artefacts that reveal traditional positivist orientations of medical education and medicine, more broadly, through their centering scientific knowledge and objective fact. This positivist orientation, however, leads to an absence of the human experience of medicine in most cases. One of the rationales for using cases is that they allow for learning in context, representing aspects of real-life medical practice in controlled environments. Cases are, therefore, a form of simulation. Yet issues of fidelity, widely discussed in the broader simulation literature, have yet to enter discussions of case-informed learning. We propose the concept of ontological fidelity as a way to approach ontological questions (i.e., questions regarding what we assume to be real), so that they might centre narrative and experiential elements of medicine. Ontological fidelity can help medical educators grapple with what information should be included in a case by encouraging an exploration of the philosophical questions: What is real? Which (and whose) reality do we want to simulate through cases? What are the essential elements of a case that make it feel real? What is the clinical story we want to reproduce in case format? In this Eye-Opener, we explore what it would mean to create cases from a position of ontological fidelity and provide suggestions for how to do this in everyday medical education.

Mapping health, social and health system issues and applying a social accountability inventory to a problem based learning medical curriculum

Social accountability is a powerful concept. It is applied to medical education to encourage future doctors to take action to address health inequalities and overlooked health needs of disadvantaged populations. Problem-based learning (PBL) provides an ideal setting to teach medical students about these topics. The objective of this study is to explore how well the components of social accountability are covered in a pre-clinical PBL medical curriculum and to determine the usefulness of an adapted validated social accountability framework. We identified Irish health needs and social issues through a literature review. The retrieved documents were aligned to four values (relevance, equity, cost-effectiveness and quality) from a validated social accountability inventory, to generate a map of social accountability values present in the Irish health system and population. We then used the adapted validated social accountability inventory to evaluate the content of the PBL medical curriculum at an Irish medical school. We identified 45 documents, which upon analysis lead to the identification of health and social issues related to social accountability. 66 pre-clinical PBL cases included demographic, health and psychosocial issues similar to the local population. Analysing along the four social accountability values, the PBL cases demonstrated room for improvement in the equity and relevance domains. Topics for expansion are Traveller health, LGBTI health, alcohol use, climate change and more. Medical educators can use the paper as an example of how to apply this methodology to evaluate PBL cases. Adapting and applying a validated framework is a useful pedagogical exercise to understand established societal values related to social accountability to inform a medical curriculum. We identified opportunities to improve the PBL cases to depict emerging global and social issues.

Virtuosic craft or clerical labour: the rise of the electronic health record and challenges to physicians' professional identity (1950-2022)

The electronic health record (EHR) is a focus of contentious debate, having become as essential to contemporary clinical practice as it is polarising. Debates about the EHR raise questions about physicians' professional identity, the nature of clinical work, evolution of the patient/practitioner relationship, and narratives of technological optimism and pessimism. The metaphors by which clinicians stake our identities-are we historians, detectives, educators, technicians, or something else?-animate the history of the early computer-based medical record in the mid-to-late twentieth-century USA. Proponents and detractors were equally interested in what the EHR revealed about clinician identity, and how it might fundamentally reshape it. This paper follows key moments in the history of the early computer-based patient record from the late 1950s to the EHR of the present day. In linking physician identity development, clinical epistemological structures, and the rise of the computer-based medical record in the USA in the mid-to-late twentieth century, we ask why the EHR is such a polarising entity in contemporary medicine, and situate clinician/EHR tensions in a longer history of aspirational physician identity and a kind of technological optimism that soon gave way to pessimism surrounding computer-based clinical work.

The Lifecycle of a Clinical Cadaver: A Practice-Based Ethnography

PhenomenonCadavers have long played an important and complex role in medical education. While research on cadaver-based simulation has largely focused on exploring student attitudes and reactions or measuring improvements in procedural performance, the ethical, philosophical, and experiential aspects of teaching and learning with cadavers are rarely discussed. In this paper, we shed new light on the fascinating philosophical moves in which people engage each and every time they find themselves face to face with a cadaver. ApproachOver a two-year period (2018/19-2019/20), we applied ethnographic methods (137 hours of observation, 24 interviews, and the analysis of 22 documents) to shadow the educational cadaver through the practical stages involved in cadaver-based simulation: 1. cadaver preparation, 2. cadaver-based skill practice with physicians and residents, and 3. interment and memorial services. We used Deleuze and Guattari's concepts of becoming and acts of creation to trace the ontological "lifecycle" of an educational cadaver as embedded within everyday work practices. FindingsWe delineated six sub-phases of the lifecycle, through which the cadaver transformed ontologically from person to donor, body, cadaver, educational cadaver, teacher, and loved one/legacy. These shifts involved a network of bureaucratic, technical, educational, and humanistic practices that shaped the way the cadaver was perceived and acted upon at different moments in the lifecycle. By highlighting, at each phase, 1) the ontological transitions of the cadaver, itself, and 2) the practices, events, settings, and people involved in each of these transitions, we explored questions of "being" as it related to the ontological ambiguity of the cadaver: its conceptualization as both person and tool, simultaneously representing life and death. InsightsEngaging deeply with the philosophical questions of cadaver-based simulation (CBS) helped us conceptualize the lifecycle as a series of meaningful and purposeful acts of becoming. Following the cadaver from program entry to interment allowed us to contemplate how its ontological ambiguity shapes every aspect of cadaver-based simulation. We found that in discussions of fidelity in medical simulation, beyond both the physical and functional, it is possible to conceive of a third type: ontological. The humanness of the cadaver makes CBS a unique, irreplaceable, and inherently philosophical, practice.

Race, ethnicity, and gender representation in clinical case vignettes: a 20-year comparison between two institutions

BACKGROUND

The medical case vignette has long been used in medical student education and frequently includes demographic variables such as race, ethnicity and gender. However, inclusion of demographic variables without context may reinforce assumptions and biases. Yet, the absence of race, sexual orientation, and social determinants of health may reinforce a hidden curriculum that reflects cultural blindness. This replication study compared proportions of race, ethnicity, and gender with University of Minnesota (UMN) findings. This study sought to determine if there has been progress in the representation of demographic characteristics in case vignettes.

METHODS

University of North Carolina (UNC) case vignettes from 2015-2016 were analyzed and compared to UMN case vignettes from 1996-1998. Data included mentions of race, ethnicity, gender and social determinants of health.

RESULTS

In the 278 UNC vignettes, white race was noted in 19.7% of cases, black race was in 7.9% cases, and 76.6% of cases were unspecified. In the 983 UMN vignettes, white race was recorded in 2.85% cases, and black race in 0.41% cases. The institutions were significantly different in the proportion of their cases depicting race (0.20; 95% CI (0.15, 0.25)). Males were represented in the majority of vignettes.

DISCUSSION

Comparing case vignettes results from two medical schools suggests that reporting explicit demographic diversity was not significantly different. The findings illustrate that sex was the demographic characteristic consistently described, where males were over-represented. Based on these findings, greater cultural diversity as it intersects with social determinants of health is needed in medical student education.

Disrupting Essentialism in Medical Genetics Education

Many traditional practices in medical genetics education need review to counteract messages of essentialism, or the belief in an underlying natural structure differentiating social categories. While genomics research increasingly disproves a genetic foundation for race, research from educational scholars demonstrates that current medical genetics instruction may actually reinforce racial bias in learners. In this monograph, we outline seven recommendations for medical educators to actively counteract essentialism, racial, and otherwise, in the genetics classroom. In particular, we emphasize the importance of engaging learners in nuanced discussions around stereotyping and its negative consequences for both accurate diagnoses and promoting health equity.

Paradox of Patient-Centered Care and the Implications for Patient Involvement in Continuing Professional Development

INTRODUCTION

Patient-centered care (PCC) is widely considered as essential in chronic disease management. As the underlying rationale for engaging patients in continuing professional development (CPD) is commonly described as fostering care that is more patient-centered, we hoped to understand the discursive conditions for how educators and health professionals can (or cannot) learn with, from, and about patients.

METHODS

Using diabetes as a case, we conducted a Foucauldian discourse analysis of an archive of relevant policy documents, professional and educational texts, to explore different conceptualizations of practice and the implications for PCC. We also conducted in-depth interviews with a purposive sample of physicians to understand their experiences in providing and teaching PCC. We sought to understand: How has PCC been discursively constructed? Whose interests does advocating PCC serve? What are the implications for patient involvement in CPD?

RESULTS

We describe three discursive constructions of PCC, each extending the reach of biomedical power. PCC as a disease intervention emphasizes knowing and relating to patients to normalize laboratory test results. PCC as a form of confession promotes patients to come to their own realizations to become responsible for their own health, but through the lens and evaluation of physicians. PCC as a disciplinary technique makes visible the possibility of using a checklist to judge physician competency in providing PCC.

DISCUSSION

PCC may be constructed in ways that paradoxically reinforce rather than challenge conventional, provider-centric paradigms. Our results challenge educators to acknowledge the existence and effects of discourses when involving patients in the planning and delivery of CPD.

Examining the Inclusion of Race and Ethnicity in Patient Cases

Health disparities continue to exist in the United States, with the most significant differences in care occurring between racial groups. Racial health disparities are largely a result of the strong association between race and structural inequities, (differentials in the distribution of power, resources, opportunities). The use of case-based learning is common practice in pharmacy education, and the race of the patient who is the subject of the case is often included out of convention. In some cases, race is included to inform treatment based on guidelines developed from epidemiological and clinical studies that link race to disease by conferring biological significance to race categories. This continuing use of race and ethnicity to guide treatment contributes to racial health disparities and may further perpetuate existing provider implicit bias. This paper discusses the pedagogical approach of using patient cases and the convention, propriety, and implications of including race in patient cases, and guides pharmacy educators in how to use information on race.

Evaluating and implementing an opportunity for diversity and inclusion in case-based learning

Problem-based learning (PBL) and case-based learning (CBL) often mention social identities only if this information is directly relevant to diagnosis, which can inadvertently perpetuate stereotypes in trainee learning. Using a student-developed resource entitled "Portraying Social Identities in Medical Curriculum: A Primer," we analyzed cases for social identities, identified gaps, and proposed changes, including use of a validated name bank to reflect diversity as represented by local census data. Through this innovation, suggestions were provided to represent the social determinants of health in CBL cases. Other medical schools can use our innovation to improve the social diversity of their medical curriculums.

Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants

Healthcare learners can gain necessary experience working with diverse and priority communities through human simulation. In this context, simulated participants (SPs) may be recruited for specific roles because of their appearance, lived experience or identity. Although one of the benefits of simulation is providing learners with practice where the risk of causing harm to patients in the clinical setting is reduced, simulation shifts the potential harm from real patients to SPs. Negative effects of tokenism, misrepresentation, stereotyping or microaggressions may be amplified when SPs are recruited for personal characteristics or lived experience. Educators have an ethical obligation to promote diversity and inclusion; however, we are also obliged to mitigate harm to SPs.

The goals of simulation (fulfilling learning objectives safely, authentically and effectively) and curricular obligations to address diverse and priority communities can be in tension with one another; valuing educational benefits might cause educators to deprioritise safety concerns. We explore this tension using a framework of diversity practices, ethics and values and simulation standards of best practice. Through the lens of healthcare ethics, we draw on the ways clinical research can provide a model for how ethical concerns can be approached in simulation, and suggest strategies to uphold authenticity and safety while representing diverse and priority communities. Our objective is not to provide a conclusive statement about how values should be weighed relative to each other, but to offer a framework to guide the complex process of weighing potential risks and benefits when working with diverse and priority communities.

Factors to Consider When Designing Multimedia CBL Tools in Health Professional Programs

Multimedia case studies are effective constructivist instructional tools that can help to design contextually authentic scenarios while also scaffolding instruction to help students move beyond their current skill and knowledge base. Although there are many advantages of using multimedia case-based learning, there are also many challenges associated with designing technology-enhanced case studies for constructivist learning. The research described herein presents the advantages and challenges that emerged from three unique learning environments in health professional education programs. In each of these environments, a multimedia educational tool (named the multimedia case-based learning sports injury assessment educational tool) was designed to engage students in authentic sport injury case scenarios. Feedback was gathered from multiple stakeholders in each learning context and used to explore the effectiveness of this technology-enhanced pedagogical approach.

The case for plural PBL: an analysis of dominant and marginalized perspectives in the globalization of problem-based learning

The globalization of problem-based learning (PBL) in health professions education has been both celebrated and criticized. Using a critical narrative review approach, underpinned by our archive of global PBL literature and a targeted literature search, we analyze these dominant global discourses of PBL in health professions education. More precisely, we explore what is missed when the globalization of PBL is theorized either as a positive consequence of standardization, or a problematic spread of Western educational ideals and values around the world. We make visible how two dominant global discourses, a universalist and culturalist discourse, have emerged in the global proliferation of PBL. We also discuss the limitations of the two discourses by demonstrating how they either ignore contextual and cultural diversity or see it as problematic. We then turn to a perspective that has been marginalized in the PBL literature that emphasizes the global origins of PBL, transcending the dichotomy between West and non-West. We make a case for relating to PBL as a plural construct in order to learn from the cultural and situational nuances of educational activities labeled PBL around the world. We argue that PBL as a singular and universal concept has no global future, yet versions of PBL may continue to thrive locally. Finally, we propose avenues for future research that may help elucidate the global and local values that underpin our curricula, as well as the socio-political factors that perpetuate neo-colonialist views and practices in the uptake and implementation of PBL approaches across the globe.

Changes to an Active Learning Curriculum in Osteopathic Medical Education: Effects on Exam Outcomes and Board Scores

With the introduction of McMaster University's problem-based, self-directed learning and cognitive integration in the medical school curriculum, learning in small groups has been gaining popularity with medical schools worldwide. Problem-based learning (PBL) places emphasis on the value of basic medical sciences as the basis of learning medicine using clinical problems. For a successful outcome, a PBL curriculum needs to have a student-centered learning environment, problem-based design and facilitation, and assessment of learning in PBL domains. We describe a PBL program that has been used for undergraduate medical education, including changes made to learning resources and assessment. The changes required input from both faculty educators and students, and success depended on buy-in into the process. One of the changes included implementing the use of standard textbooks, which students use as the primary source of information during self-directed learning. Another change was the use of several reliable, valid, and cost-effective high-stakes written exams from internal and external sources, to promote spaced retrieval of biomedical facts and clinical contexts. By making these and other changes, we have been able to achieve pass rates and board scores which are consistently above the national average for 12 years. We conclude that in order to ensure sustainable successful outcomes, it is important to keep our program dynamic by making improvements in the PBL domains and assessment methods, taking into consideration students' course evaluations of the learning environment.

Problems of problem-based learning: Towards transformative critical pedagogy in medical education

Problem-based medical education is based in a biomedical worldview that works to entrench deterministic ways of thinking about socioculturally-influenced health disparities in the minds of medical trainees. This perspective paper considers the utility of Paolo Freire's critical pedagogy as a means of redressing this issue, as it may enable medical learners to perceive and address the social sources of illness that shape their patients' lives. With an eye to advancing health equity, and educating health professionals who are responsive to marginalized and vulnerable communities, this paper considers how a problem-posing medical education could redefine physicians' relationships to knowledge, identity, and to their patients.

Comparing and Contrasting the Use of Problem-Based Learning in Child and Adolescent Psychiatry Programs

OBJECTIVE

Problem-based learning (PBL) is one of the core components of medical education. To facilitate the spread and use of PBL in child and adolescent psychiatry (CAP) fellowship training, a special interest study group (SISG) was formed at the American Academy of Child and Adolescent Psychiatry (AACAP). Different approaches to the implementation of PBL between programs represented at the SISG are compared in this report.

METHODS

The authors distributed a survey to SISG participants after the 2015 annual AACAP meeting, which gathered information about the different approaches programs use to implement PBL in graduate medical education.

RESULTS

Six CAP training programs responded to the survey, providing descriptions of the structure and content of PBL seminars. Programs chose to include a wide variety of topics in PBL courses and approach course organization in a number of ways. To the degree that PBL draws from identified reference texts, programs were similar in selecting definitive textbooks, practice parameters, and seminal articles.

CONCLUSIONS

This small pilot study is intended to provide a snapshot of the state of PBL implementation in CAP fellowship programs. It reflects that programs can incorporate PBL in a variety of ways, tailored to the needs of the institution. Future directions of research include assessment of resident satisfaction with PBL, impact on resident education, and identifying successful methods of implementation of PBL.

The Irrelevance Narrative: Queer (In)Visibility in Medical Education and Practice

How might heteronormativity be reproduced and become internalized through biomedical practices? Based on in-depth, person-centered interviews, this article explores the ways heteronormativity works into medical education through the hidden curriculum. As experienced by my informants, case studies often reinforce unconscious heteronormative orientations and heterosexist/homophobic stereotypes about queer patients among straight and queer medical students alike. I introduce the concept of the irrelevance narrative to make sense of how queer medical students take up a heteronormative medical gaze. Despite recognizing that being queer affects how they interact with patients, my informants describe being queer as irrelevant to their delivery of care. I conclude with a discussion of how these preliminary findings can inform research on knowledge production in biomedical education and practice with an eye toward the tensions between personal and professional identity among biomedical practitioners.

Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School

PHENOMENON: Homelessness is a major public health concern. Given that homeless individuals have high rates of mortality and morbidity, are more likely to be users of the healthcare system, and often report unmet health needs, it is important to examine how homelessness is addressed in medical education. We wanted to examine content and framing of issues related to homelessness in the case-based learning (CBL) curriculum and provide insights about whether medical students are being adequately trained to meet the health needs of homeless individuals through CBL.

APPROACH

CBL content at a Canadian medical school that featured content related to homelessness was analyzed. Data were extracted from cases for the following variables: curriculum unit (e.g., professionalism/ethics curriculum or biomedical/clinical curriculum), patient characteristics (e.g., age, sex), and medical and social conditions. A thematic analysis was performed on cases related to homelessness. Discrepancies in analysis were resolved by consensus.

FINDINGS

Homelessness was mentioned in five (2.6%) of 191 CBL cases in the medical curriculum. Homelessness was significantly more likely to be featured in professionalism/ethics cases than in biomedical/clinical cases (p = .03). Homeless patients were portrayed as socially disadvantaged individuals, and medical learners were prompted to discuss ethical issues related to homeless patients in cases. However, homeless individuals were largely voiceless in cases. Homelessness was associated with serious physical and mental health concerns, but students were rarely prompted to address these concerns. Insights: The health and social needs of homeless individuals are often overlooked in CBL cases in the medical curriculum. Moreover, stereotypes of homelessness may be reinforced through medical training. There are opportunities for growth in addressing the needs of homeless individuals through medical education.

Exploring the efficacy of replacing linear paper-based patient cases in problem-based learning with dynamic Web-based virtual patients: randomized controlled trial

Background

Problem-based learning (PBL) is well established in medical education and beyond, and continues to be developed and explored. Challenges include how to connect the somewhat abstract nature of classroom-based PBL with clinical practice and how to maintain learner engagement in the process of PBL over time.

Objective

A study was conducted to investigate the efficacy of decision-PBL (D-PBL), a variant form of PBL that replaces linear PBL cases with virtual patients. These Web-based interactive cases provided learners with a series of patient management pathways. Learners were encouraged to consider and discuss courses of action, take their chosen management pathway, and experience the consequences of their decisions. A Web-based application was essential to allow scenarios to respond dynamically to learners’ decisions, to deliver the scenarios to multiple PBL classrooms in the same timeframe, and to record centrally the paths taken by the PBL groups.

Methods

A randomized controlled trial in crossover design was run involving all learners (N=81) in the second year of the graduate entry stream for the undergraduate medicine program at St George’s University of London. Learners were randomized to study groups; half engaged in a D-PBL activity whereas the other half had a traditional linear PBL activity on the same subject material. Groups alternated D-PBL and linear PBL over the semester. The measure was mean cohort performance on specific face-to-face exam questions at the end of the semester.

Results

D-PBL groups performed better than linear PBL groups on questions related to D-PBL with the difference being statistically significant for all questions. Differences between the exam performances of the 2 groups were not statistically significant for the questions not related to D-PBL. The effect sizes for D-PBL–related questions were large and positive (>0.6) except for 1 question that showed a medium positive effect size. The effect sizes for questions not related to D-PBL were all small (≤0.3) with a mix of positive and negative values.

Conclusions

The efficacy of D-PBL was indicated by improved exam performance for learners who had D-PBL compared to those who had linear PBL. This suggests that the use of D-PBL leads to better midterm learning outcomes than linear PBL, at least for learners with prior experience with linear PBL. On the basis of tutor and student feedback, St George’s University of London and the University of Nicosia, Cyprus have replaced paper PBL cases for midstage undergraduate teaching with D-PBL virtual patients, and 6 more institutions in the ePBLnet partnership will be implementing D-PBL in Autumn 2015.

Virtual patients as activities: exploring the research implications of an activity theoretical stance

Virtual patients are computer-based simulators of patient encounters for the purposes of instruction, practice, and assessment. Although virtual patients have been around for some time they have yet to become part of mainstream medical education. A major reason for this would seem to be a lack of clarity as to what educational value virtual patients actually have. This paper argues that virtual patients should be seen as activities rather than artifacts and that activity theory can be used to generate different ways to frame scholarship in and around virtual patients. Drawing on the work of Leont'ev and Engeström this paper describes a range of perspectives based on the operations, actions, and objectives in and around virtual patients; the use of virtual patients to mediate activities; and the sociocultural context and the participants in virtual patient activities. This approach allows us to move beyond the 'does or does not work' discourse of much of the existing scholarship around virtual patients and, to an extent, around educational technologies as a whole. Activity perspectives, and activity theory in particular, offer new horizons for research and evaluation that address many of the limitations of intervention-based paradigms of inquiry.

The spectre of race in American medicine

Controversies and debates surrounding race have long been a fixture in American medicine. In the past, the biological concept of race-the idea that race is biologically determined and meaningful-has served to justify the institution of slavery and the conduct of unethical research trials. Although these days may seem far behind, contemporary debates over the race-specific approval of drugs and the significance of genetic differences are evidence that race still yields tremendous influence on medical research and clinical practice. In many ways, the use of race in medicine today reflects the internalisation of racial hierarchies borne out of the history of slavery and state-mandated segregation, and there is still much uncertainty over its benefits and harms. Although using race in research can help elucidate disparities, the reflexive use of race as a variable runs the risk of reifying the biological concept of race and blinding researchers to important underlying factors such as socioeconomic status. Similarly, in clinical practice, the use of race in assessing a patient's risk of certain conditions (eg, sickle cell) turns harmful when the heuristic becomes a rule. Through selected historical and contemporary examples, I aim to show how the biological concept of race that gave rise to past abuses remains alive and harmful, and propose changes in medical education as a potential solution. By learning from the past, today's physicians will be better armed to discern-and correct-the ways in which contemporary medicine perpetuates historical injustices.

More than an education: the hidden curriculum, professional attitudes and career choice

OBJECTIVES

In this qualitative study we examine how teachers' egalitarian or discriminatory behaviours and values at odds with those of the individual learner or the institution are perceived and absorbed by students, and how this hidden curriculum shapes the doctors students become.

METHODS

During 2011, a total of 120 randomly selected medical students from each class at three Canadian medical schools were electronically asked for examples of teachers' words, attitudes or behaviours that discriminated against or promoted equality towards a group or groups of doctors or patients. We examined the content of participants' examples of unexpected messages and their reactions to these. Responses were aggregated, sorted and coded for conceptual themes. An independent qualitative researcher repeated the analytic process and then engaged in discussion with us to reach consensus on themes and meanings.

RESULTS

The 76 (63%) respondents noted that attitudes in keeping with universally held, institutional values of equality towards, for example, homosexuals or marginalised populations were expressed, but also described role-modelling at odds with this. Patient characteristics such as obesity, drug abuse, mental illness and poverty were presented as signs of individual weakness or moral failing. Some teachers assumed immigrant status based on a student's or patient's skin colour or last name. Respondents described how women in medicine were maligned as potential surgeons and were expected to put family before career. Teachers denigrated doctors from specialties other than their own. Students reacted to discordant role-modelling by challenging, dissociating themselves, with silence or with confusion followed by attempts at individual transformation to realign careers and behaviours with those of teachers.

CONCLUSIONS

When teaching contradicts institutional or learners' values, or is particularly inspiring, students notice and may be influenced to the extent that they rethink personal beliefs and plans to fit their future doctor selves to these models.

Video-based cases disrupt deep critical thinking in problem-based learning

CONTEXT

  Video is a popular tool in problem-based learning (PBL), although its production requires resources and time. Few studies have examined the impact of the use of video in PBL upon cognitive processes and critical thinking. Those that have done focused on cases involving physical signs, where video has natural advantages.

OBJECTIVES

  This study aimed to investigate preferences for video- or text-based cases and the effects of each format upon medical students' deep thinking in PBL. Tutorials were based on material portraying interviews with patients with conditions that include psychosocial elements but no physical signs.

METHODS

  Four tutorial groups of students in a Year 2 endocrine and reproductive pathophysiology course participated in a crossover study using one video-based and one text-based case. Transcripts of tutorials were coded for depth of thinking by a blinded coder. A generalised estimating equation model was used to adjust for potential differences among groups, cases, and tutor participation. The distribution of cognitive activity within the crossover groups and the adjusted odds ratios (ORs) for deep versus superficial thinking were calculated. A prior cohort of 165 students and 18 tutors completed a survey of learning preferences.

RESULTS

  Of 5224 student utterances, the majority referred to problem exploration (2622, 50%) and description (1479, 28%). Overall, the odds of deep thinking versus superficial thinking were significantly lower using video-based cases compared with text-based cases (2045 deep/2454 for video versus 1961 deep/2218 for text; OR 0.663, 95% confidence interval [CI] 0.582-0.754; p < 0.0001). This was also true for the problem exploration domain (1217 deep/1365 for video versus 1178 deep/1257 for text; OR 0.559, 95% CI 0.355-0.882; p = 0.0125). The majority of students (59%) and tutors (78%) indicated a preference for video-based cases over text-based cases.

CONCLUSIONS

  Students and their tutors prefer video-based cases in PBL. However, compared with text-based material, the use of video-based material that refers to cases without dynamic physical signs is associated with a reduction in deep thinking.

Deliberative curriculum inquiry for integration in an MD curriculum: Dalhousie University's curriculum renewal process

BACKGROUND

Dalhousie University's MD Programme faced a one-year timeline for renewal of its undergraduate curriculum.

AIM

Key goals were renewed faculty engagement for ongoing quality improvement and increased collaboration across disciplines for an integrated curriculum, with the goal of preparing physicians for practice in the twenty-first century.

METHODS

We engaged approximately 600 faculty members, students, staff and stakeholders external to the faculty of medicine in a process described by Harris (1993) as 'deliberative curriculum inquiry'. Temporally overlapping and networked intraprofessional and interprofessional teams developed programme outcomes, completed environment scans of emerging content and best practices, and designed curricular units.

RESULTS

The resulting curriculum is the product of new collaborations among faculty and exemplifies distinct forms of integration. Innovations include content and cases shared by concurrent units, foundations courses at the beginning of each year and integrative experiences at the end, and an interprofessional community health mentors programme.

CONCLUSION

The use of deliberative inquiry for pre-med curriculum renewal on a one-year time frame is feasible, in part through the use of technology. Ongoing structures for integration remain challenging. Although faculty collaboration fosters integration, a learner-centred lens must guide its design.

Living and working with the people of 'the bush': a foundation for rural and remote clinical placements in undergraduate medical education

BACKGROUND

The Australian Government's policies and programmes to redress the medical workforce shortage in rural and remote areas focus on recruitment of rural students and provision of rural clinical placements. The University of Notre Dame's Rural and Remote Health Placement Programme (RRHPP) uses an additional approach to address this issue.

AIM

This article describes the RRHPP undertaken by all medical students in the first 2-years of their course and examines the educational worth of this approach.

METHOD

Data were obtained from curricular documents, publications about the RRHPP and evaluation questionnaires administered to students and supervisors.

RESULTS

The RRHPP provides students with opportunities to develop a patient- and community-centred perspective on the health issues of rural and remote populations by having them live and work with people in these areas prior to clinical placements. It is based on sound educational principles and underpinned by participation of rural/remote communities as experts and equal teaching partners. The RRHPP is valued and perceived by a majority of students and placement hosts as a useful strategy to develop medical students' understanding of the rural/remote community context and its impact on health.

CONCLUSION

This community participatory approach benefits medical students and rural/remote communities.