1
|
Millar JK, Matusko N, Evans J, Sandhu G. Faculty perception of resident promotion and prevention associated behaviors in the operating room to facilitate intra-operative learning. Am J Surg 2024; 234:3-8. [PMID: 38182458 DOI: 10.1016/j.amjsurg.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/05/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Previous work has demonstrated that residents are able to accurately perceive the intraoperative motivational style of faculty. Additionally, alignment of motivational style between residents and faculty has been demonstrated to enhance resident intraoperative autonomy. This study evaluated if faculty perception of resident behaviors aligned with resident self-perception in order to identify ways of enhancing intraoperative learning. METHODS General surgery residents were asked to complete a self-assessment evaluating their own intraoperative behaviors. Conversely, faculty rated how strongly the residents exhibited these behaviors in the operating room. RESULTS Of the 10 intraoperative behaviors that were evaluated, eight demonstrated no correlation between resident self-perception and faculty perception of resident behavior. Similarly, inconsistent correlations emerged when behaviors were assessed according to the self-reported gender and race of the resident. CONCLUSION Faculty are not able to accurately perceive the motivational style of residents. Strategies to improve faculty perception of resident motivational style may enhance intraoperative learning.
Collapse
Affiliation(s)
- Jessica K Millar
- Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, United States; Department of Cardiac Surgery, University of Michigan, 1425 E. Ann St, Ann Arbor, MI, 48109, United States.
| | - Niki Matusko
- Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, United States.
| | - Julie Evans
- Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, United States.
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, United States.
| |
Collapse
|
2
|
Carvey MMT, Omidvar AA, Wan EE, Hynes AM, Lentz SA. Effectiveness of the Introduction to Critical Care in Emergency Medicine Curriculum's Implementation Among Trainees Interested in Intensive Care. J Emerg Med 2024; 67:e80-e88. [PMID: 38806349 DOI: 10.1016/j.jemermed.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/11/2024] [Accepted: 03/06/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Emergency physicians and trainees provide the initial care for critically ill patients. In times of emergency department boarding, this care may extend beyond the first few hours. To meet the needs of this population, a standardized novel critical care curriculum targeting third- and fourth-year medical students was developed. OBJECTIVES We hypothesized that the institution of such a curriculum is feasible and will provide an increased understanding of the underlying critical care principles within this learner population. METHODS We developed a 2-month-long critical care curriculum (February-April) and carried out the course twice from 2022-2023. Our pilot study deployed this curriculum to medical students interested in critical care through the American Academy of Emergency Medicine/Resident and Student Association. The primary outcome included was the overall composite score comparison of the pre- and post-course evaluations, with a higher score indicating that the student improved their comprehension. Secondary outcomes included the individual factors of the pre- and post-course surveys. RESULTS Fifty-one trainees completed the pilot course, including 11/51 (21.6%) third-year medical students and 40/51 (78.4%) fourth-year medical students. Overall, 39 had "no experience" in critical care and 12 indicated that they had "previous experience." The students' baseline pre-course from the pooled 2022 and 2023 Introduction to Critical Care in Emergency Medicine (ICCEM) curriculum data was 3 (interquartile range 4-3) and their post-course score was 9 (interquartile range 9-9), p-value 0.015 for the 51/54 students who completed the course. CONCLUSIONS The novel curriculum was found to be effective during its implementation in third- and fourth-year medical students. As such, it indicated that a critical care fundamentals course improves confidence in these topics for students with and without prior experience. Further work is necessary to understand the generalizability and knowledge retention of the proposed pilot curriculum.
Collapse
Affiliation(s)
- Matthew M T Carvey
- Department of Emergency Medicine, MetroHealth/Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ava A Omidvar
- St. George's University, School of Medicine, St. George, Grenada
| | - Elias E Wan
- Department of Surgery, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Allyson M Hynes
- Department of Emergency Medicine; Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Skyler A Lentz
- Department of Emergency Medicine and Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| |
Collapse
|
3
|
Burke AE, Sklansky DJ, Haftel HM, Mitchell A, Mann KJ. Competency-based medical education and the education continuum: Establishing a framework for lifelong learning. Curr Probl Pediatr Adolesc Health Care 2024:101642. [PMID: 38851971 DOI: 10.1016/j.cppeds.2024.101642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Affiliation(s)
- Ann E Burke
- Wright State University Boonshoft School of Medicine and Dayton Children's Hospital.
| | - Daniel J Sklansky
- University of Wisconsin School of Medicine and Public Health and American Family Children's Hospital
| | - Hilary M Haftel
- American Academy of Pediatrics, Senior Vice President, Education
| | - Andrew Mitchell
- Wright State University Boonshoft School of Medicine and Dayton Children's Hospital
| | - Keith J Mann
- American Board of Pediatrics, Vice President for Continuing Certification
| |
Collapse
|
4
|
Caretta-Weyer HA, Park YS, Tekian A, Sebok-Syer SS. The Inconspicuous Learner Handover: An Exploratory Study of U.S. Emergency Medicine Program Directors' Perceptions of Learner Handovers from Medical School to Residency. TEACHING AND LEARNING IN MEDICINE 2024; 36:134-142. [PMID: 36794363 DOI: 10.1080/10401334.2023.2178438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 01/13/2023] [Accepted: 01/31/2023] [Indexed: 06/18/2023]
Abstract
Phenomenon: Central to competency-based medical education is the need for a seamless developmental continuum of training and practice. Trainees currently experience significant discontinuity in the transition from undergraduate (UME) to graduate medical education (GME). The learner handover is intended to smooth this transition, but little is known about how well this is working from the GME perspective. In an attempt to gather preliminary evidence, this study explores U.S. program directors (PDs) perspective of the learner handover from UME to GME. Approach: Using exploratory qualitative methodology, we conducted semi-structured interviews with 12 Emergency Medicine PDs within the U.S. from October to November, 2020. We asked participants to describe their current perception of the learner handover from UME to GME. Then we performed thematic analysis using an inductive approach. Findings: We identified two main themes: The inconspicuous learner handover and barrier to creating a successful UME to GME learner handover. PDs described the current state of the learner handover as "nonexistent," yet acknowledged that information is transmitted from UME to GME. Participants also highlighted key challenges preventing a successful learner handover from UME to GME. These included: conflicting expectations, issues of trust and transparency, and a dearth of assessment data to actually hand over. Insights: PDs highlight the inconspicuous nature of learner handovers, suggesting that assessment information is not shared in the way it should be in the transition from UME to GME. Challenges with the learner handover demonstrate a lack of trust, transparency, and explicit communication between UME and GME. Our findings can inform how national organizations establish a unified approach to transmitting growth-oriented assessment data and formalize transparent learner handovers from UME to GME.
Collapse
Affiliation(s)
- Holly A Caretta-Weyer
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yoon Soo Park
- Department of Medical Education and Office of International Education, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ara Tekian
- Department of Medical Education and Office of International Education, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Stefanie S Sebok-Syer
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
5
|
Dyster T, Santhosh L. Beyond the Procedure Log: Using Individualized Learning Plans to Set Learner-Specific Milestones for Procedural Skills Acquisition. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:381-387. [PMID: 38113441 DOI: 10.1097/acm.0000000000005593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
ABSTRACT Procedural training for nonsurgical fields, such as internal medicine, is an important component of medical education. However, recent changes to accreditation guidelines have resulted in less formal guidance on procedural competency, not only leading to opportunities for individualizing training but also creating potential problems for trainees and training programs. In this article, the authors use internal medicine as an exemplar to review current strategies for procedural education in nonsurgical fields, including procedural simulation, dedicated procedural rotations, and advanced subspecialty training, and highlight an emerging need for learner-specific terminal milestones in procedural training. Individualized learning plans (ILPs), collections of trainee-specific objectives for learning, are arguably a useful strategy for organizing procedural training. The role of ILPs as a framework to support setting learner-specific terminal milestones, guide skill acquisition, and allocate procedural learning opportunities based on trainees' anticipated career plans is subsequently explored, and how an ILP-based approach might be implemented within the complex educational milieu of a clinical training program is examined. The limitations and pitfalls of an ILP-based approach, including the need for development of coaching programs, are considered. The authors conclude that, despite the limitations of ILPs, when combined with other current strategies for building trainees' procedural competence, these plans may help trainees maximize the educational benefits of their training period and can encourage effective, safer, and equitable allocation of procedural practice opportunities.
Collapse
|
6
|
Hanson JL, Christy C, Clarke D, Green CM, Jirasevijinda TJ, Khidir A, Kind T, Levine L, Paul CR, Powers M, Rocha MEM, Sanguino SM, Schiller J, Tenney-Soeiro R, Trainor JL, Tewksbury LR. What Do Pediatric Subinterns Say About Their Learning and Assessment? A Qualitative Analysis of Individual Learning Plans. Acad Pediatr 2024; 24:359-368. [PMID: 37907127 DOI: 10.1016/j.acap.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To perform a qualitative content analysis of learning and assessment strategies that pediatric subinterns describe in Individualized Learning Plans (ILPs) and to explore barriers and facilitators to their learning. METHODS We analyzed ILPs from medical students enrolled in pediatric subinternships at 10 US medical schools that utilized a standardized curriculum and were recruited to reflect diversity in geographic location, funding, and enrollment. Students used an ILP to record 3 or more selected learning objectives, rationale for selection, and reflection on learning and assessment strategies. Investigators used the constant comparative method to perform a content analysis of the ILPs, grouping codes into themes, and verifying relationships between codes within themes. RESULTS Two hundred and four ILPs that included student reflections on 850 learning objectives were analyzed. Content was analyzed in 5 categories: rationale for selecting objectives, learning strategies, assessment strategies, challenges to learning, and facilitators of learning. Students showed strong commitment to individualized, self-directed learning, developed a wide range of creative learning strategies, and relied heavily on self-reflection to assess their progress. The learning environment both helped and hindered students' ability to make and assess progress on their selected learning objectives. CONCLUSIONS Through ILP-guided reflection and a formal curriculum, students can choose well-justified learning objectives and demonstrate resourcefulness and independence in developing self-directed learning and assessment strategies. The strategies that students identified in this study provide a menu of learning and assessment options for subinterns. Identified challenges and facilitators of learning provide guidance for educators who seek to enhance the clinical learning environment.
Collapse
Affiliation(s)
- Janice L Hanson
- Department of Medicine (JL Hanson), Uniformed Services University of the Health Sciences, Bethesda, Md. Dr Hanson is now with the Washington University in St. Louis School of Medicine, St. Louis, Mo.
| | - Cynthia Christy
- Department of Pediatrics (C Christy), University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Daxa Clarke
- Department of Pediatrics (D Clarke), The University of Arizona College of Medicine-Phoenix, Phoenix, Ariz.
| | - Cori M Green
- Department of Pediatrics (CM Green and TJ Jirasevijinda), Weill Cornell Medical College, New York, NY.
| | - T J Jirasevijinda
- Department of Pediatrics (CM Green and TJ Jirasevijinda), Weill Cornell Medical College, New York, NY.
| | - Amal Khidir
- Department of Medical Education (A Khidir), Weill Cornell Medicine-Qatar, Ar-Rayyan, Qatar.
| | - Terry Kind
- Department of Pediatrics (T Kind), George Washington University, Children's National Hospital, Washington, DC.
| | - Leonard Levine
- Department of Pediatrics (L Levine), Drexel University College of Medicine, Philadelphia, Pa. Dr Levine is now with the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa.
| | - Caroline R Paul
- Department of Pediatrics (CR Paul), University of Wisconsin School of Medicine and Public Health, Madison, Wis. Dr Paul is now with the Department of Pediatrics, NYU Grossman School of Medicine, New York, NY.
| | - Makia Powers
- Department of Pediatrics (M Powers), Morehouse School of Medicine, Atlanta, Ga. Dr Powers is now with Morehouse School of Medicine, Aetna, a CVS Health Company, Blueberry Pediatrics, Atlanta, Ga.
| | - Mary Esther M Rocha
- Department of Pediatrics (MEM Rocha), Baylor College of Medicine, Houston, Tex.
| | - Sandra M Sanguino
- Department of Pediatrics (SM Sanguino and JL Trainor), Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Jocelyn Schiller
- Department of Pediatrics (J Schiller), University of Michigan Medical School, Ann Arbor, Mich.
| | - Rebecca Tenney-Soeiro
- Department of Pediatrics (R Tenney-Soeiro), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - Jennifer L Trainor
- Department of Pediatrics (SM Sanguino and JL Trainor), Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Linda R Tewksbury
- Department of Pediatrics (LR Tewksbury), NYU Grossman School of Medicine, New York, NY.
| |
Collapse
|
7
|
Bilyeu CA, McDevitt AW, Judd DL. A blended approach to developing psychomotor skills in novice learners in a doctor of physical therapy curriculum. MEDICAL TEACHER 2024; 46:196-203. [PMID: 37506222 DOI: 10.1080/0142159x.2023.2240001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
PURPOSE Psychomotor skill performance is central to effective clinical practice across health professions. These complex skills are challenging to teach, particularly in the novice learner. As many health professions programs have increased blended course offerings, educators must establish best practices for teaching psychomotor skills in this evolving learning environment. The purpose of this paper is to describe the innovative application of an evidence-based framework to teaching psychomotor skills to novice learners in a blended learning environment. MATERIALS AND METHODS Using a modified 9-step framework, two novice clinical skills courses in a Doctor of Physical Therapy Program were redesigned to teach psychomotor skills in a blended format, using online and in-person class sessions. Online coursework consisted of synchronous and asynchronous learning activities that preceded an immersive lab experience. Formative and summative assessments occurred during lab immersion. RESULTS AND CONCLUSIONS The learning framework provided a central evidence-based pillar for novel course design, guiding development of learning activities for teaching psychomotor skills to novice learners in a blended learning environment. Initial student outcomes appear favorable when compared with previous traditional course structures and satisfaction was high. These preliminary findings align with prior research using similar frameworks for learning complex skills and provide an archetype curricular model for a blended learning environment.
Collapse
Affiliation(s)
- Catherine A Bilyeu
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy W McDevitt
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Dana L Judd
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
8
|
Wykowski JH, Kelly ME, Tong HH, Osobamiro OO, Albert TJ. An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences. J Gen Intern Med 2024; 39:481-486. [PMID: 37989816 PMCID: PMC10897115 DOI: 10.1007/s11606-023-08399-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/24/2023] [Indexed: 11/23/2023]
Abstract
Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.
Collapse
Affiliation(s)
- James H Wykowski
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Molly E Kelly
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Hao H Tong
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Tyler J Albert
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| |
Collapse
|
9
|
Abraham C. A Medical Student Obstetric Curriculum Consisting of Online Modules and a Normal Spontaneous Vaginal Delivery Simulation Exercise. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205241245295. [PMID: 38577486 PMCID: PMC10993665 DOI: 10.1177/23821205241245295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/19/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE In many medical schools, students are exposed to obstetrics for 2 weeks during the third-year obstetrics and gynecology clerkship. Hence, the purpose of this study was to evaluate the effectiveness of a curriculum combining online obstetric modules and a normal spontaneous vaginal delivery (NSVD) simulation on medical student knowledge and comfort pertaining to obstetrics at the start of the clerkship. METHODS Students completed the curriculum at the start of the clerkship. They completed questionnaires before and after each module and the simulation. The questionnaires assessed knowledge, management comfort level, and satisfaction with module/simulation. Comfort level and satisfaction scores were based on a 1-5 Likert scale (1 = very uncomfortable/unfavorable, 5 = very comfortable/favorable). Satisfaction scores for online modules were compared with those for a historical cohort of traditional lectures on the same topics. Students also rated satisfaction with the curriculum. RESULTS Sixty students participated. Mean knowledge and comfort scores significantly increased from 7.2 to 9.2 (P < .001) and from 2.7 to 3.9 (P < .001) before and after the modules, respectively. Although satisfaction scores for traditional lectures were significantly higher than for online modules (4.7 vs. 4.4, P < .001), online modules were still favorably received. Mean satisfaction score for the NSVD simulation was 4.8. Overall, satisfaction score for the curriculum was 4.5. DISCUSSION An obstetric curriculum consisting of online modules and simulation significantly increases medical student learner knowledge and comfort and is associated with a high level of satisfaction.
Collapse
Affiliation(s)
- Cynthia Abraham
- Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine at Mount Sinai and Mount Sinai Health System, New York, NY, USA
- Department of Medical Education, Icahn School of Medicine at Mount Sinai and Mount Sinai Health System, New York, NY, USA
| |
Collapse
|
10
|
Klig JE, Stenson BA, Kivlehan SM, Jackson A, Berwick JR, Kosowsky JM. Twelve tips for practical clinical skills coaching. MEDICAL TEACHER 2023; 45:1357-1363. [PMID: 37318542 DOI: 10.1080/0142159x.2023.2220895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Coaching is rapidly evolving in clinical medicine, including for clinical skills (CS) learning. Yet a schema is needed for how to coach students in the many CS that are pivotal to the practice of medicine. These twelve tips aim to provide practical strategies for teachers and educators to coach students for CS learning. The tips cover many important aspects of CS coaching, including establishing a safe space, ways to prepare to coach, setting goals, guiding a coaching relationship, fostering coaching conversations, and in-person or virtual approaches. Together, the tips align as seven key steps of an overall coaching process. The twelve tips apply equally to coaching struggling students and all students seeking to improve CS and offer a guide for coaching at an individual or program level.
Collapse
Affiliation(s)
- Jean E Klig
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Office of Medical Education, Harvard Medical School, Boston, MA, USA
| | - Bryan A Stenson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sean M Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Agnieszka Jackson
- Office of Medical Education, Harvard Medical School, Boston, MA, USA
| | - Jessica R Berwick
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua M Kosowsky
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
11
|
LeClair RJ, Binks AP, Gambala CT, Brenner JM, Willey JM. The Impact of Changing Step 1 to Pass/Fail Reporting on Anxiety, Learning Approaches, and Curiosity. MEDICAL SCIENCE EDUCATOR 2023; 33:1197-1204. [PMID: 37886271 PMCID: PMC10597890 DOI: 10.1007/s40670-023-01878-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 10/28/2023]
Abstract
Purpose Given the significance of the US Medical Licensing Exam (USMLE) Step 1 score moving from a 3-digit value to pass/fail, the authors investigated the impact of the change on students' anxiety, approach to learning, and curiosity. Method Two cohorts of pre-clerkship medical students at three medical schools completed a composite of four instruments: the State-Trait Anxiety Inventory, the revised two-factor Study Process Questionnaire, the Interest/Deprivation Type Epistemic Curiosity Scale, and the Short Grit Scale prior to taking the last 3-digit scored Step 1 in 2021 or taking the first pass/fail scored Step 1 in 2022. Responses of 3-digit and pass/fail exam takers were compared (Mann-Whitney U) and multiple regression path analysis was performed to determine the factors that significantly impacted learning strategies. Results There was no difference between 3-digit (n = 86) and pass/fail exam takers (n = 154) in anxiety (STA-I scores, 50 vs. 49, p = 0.85), shallow learning strategies (22 vs. 23, p = 0.84), or interest curiosity scores (median scores 15 vs. 15, p = 0.07). However, pass/fail exam takers had lower deprivation curiosity scores (median 12 vs. 11, p = 0.03) and showed a decline in deep learning strategies (30 vs. 27, p = 0.0012). Path analysis indicated the decline in deep learning strategies was due to the change in exam scoring (β = - 2.0428, p < 0.05). Conclusions Counter to the stated hypothesis and intentions, the initial impact of the change to pass/fail grading for USMLE Step 1 failed to reduce learner anxiety, and reduced curiosity and deep learning strategies. Supplementary Information The online version contains supplementary material available at 10.1007/s40670-023-01878-w.
Collapse
Affiliation(s)
- Renée J. LeClair
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA USA
| | - Andrew P. Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA USA
| | - Cecilia T. Gambala
- Office of Academic Affairs, Tulane University School of Medicine, New Orleans, LA USA
| | - Judith M. Brenner
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
- New York University Grossman Long Island School of Medicine, Mineola, USA
| | - Joanne M. Willey
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
| |
Collapse
|
12
|
Goins SM, French RJ, Martin JG. The Use of Structured Oral Exams for the Assessment of Medical Students in their Radiology Clerkship. Curr Probl Diagn Radiol 2023; 52:330-333. [PMID: 37032291 DOI: 10.1067/j.cpradiol.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/16/2023] [Indexed: 04/11/2023]
Abstract
RATIONALE & OBJECTIVES There is increasing interest in narrative feedback and competency-based evaluation in medical student education. This study evaluates the implementation of a structured oral exam for a required radiology clerkship in furtherance of these aims. MATERIALS & METHODS A structured oral exam was instituted in academic year (AY) 20-21. Students prepared to discuss 5 varied imaging cases as they would to a medical colleague and as to a patient. For AY 20-21, students took the oral and a written exam. In AY 21-22, students took the oral exam alone and the written exam was discontinued. The perceived educational value of clerkship components, including the oral and written exam, were scored by the students on a 5-point Likert scale. RESULTS All students in AY 20-21 received a passing score on the written (mean 89.0, SD 4.59) and oral exams. All students in AY 21-22 received a passing score on the oral exam. In AY 20-21, the educational value of the oral exam was rated significantly higher than that of the written exam (4.30 vs 4.02, P = 0.021). There was no significant difference in rating of the oral exam between AY 20-21 and AY 21-22 (4.30 vs 4.38; P = 0.499). CONCLUSION The implementation of a structured final oral exam for a required radiology clerkship was felt to be successful in the aims of delivering educational value while evaluating students for competency. Further evaluation of oral exams for radiology medical student education are warranted to optimize the career preparation of future physicians.
Collapse
Affiliation(s)
| | - Robert J French
- Department of Radiology, Duke University School of Medicine, Durham, NC
| | - Jonathan G Martin
- Department of Radiology, Duke University School of Medicine, Durham, NC.
| |
Collapse
|
13
|
Petrosoniak A, Sherbino J, Beardsley T, Bonz J, Gray S, Hall AK, Hicks C, Kim J, Mastoras G, McGowan M, Owen J, Wong AH, Monteiro S. Are we talking about practice? A randomized study comparing simulation-based deliberate practice and mastery learning to self-guided practice. CAN J EMERG MED 2023; 25:667-675. [PMID: 37326922 DOI: 10.1007/s43678-023-00531-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Simulation-based technical skills training is now ubiquitous in medicine, particularly for high acuity, low occurrence (HALO) procedures. Mastery learning and deliberate practice (ML + DP) are potentially valuable educational methods, however, they are resource intensive. We sought to compare the effect of deliberate practice and mastery learning versus self-guided practice on skill performance of the rare, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC). METHODS We conducted a multi-center, randomized study at five North American emergency medicine (EM) residency programs. We randomly assigned 176 EM residents to either the ML + DP or self-guided practice groups. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test), after (post-test) and 6-12 months (retention) after the training session. The primary outcome was post-test skill performance using a global rating score (GRS). Secondary outcomes included performance time and skill performance at the retention test. RESULTS Immediately following training, GRS scores were significantly higher as mean performance improved from pre-test, (22, 95% CI = 21-23) to post-test (27, 95% CI = 26-28), (p < 0.001) for all participants. However, there was no difference between the groups on GRS scores (p = 0.2) at the post-test or at the retention test (p = 0.2). At the retention test, participants in the ML + DP group had faster performance times (66 s, 95% CI = 57-74) compared to the self-guided group (77 s, 95% CI = 67-86), (p < 0.01). CONCLUSIONS There was no significant difference in skill performance between groups. Residents who received deliberate practice and mastery learning demonstrated an improvement in skill performance time.
Collapse
Affiliation(s)
- Andrew Petrosoniak
- Division of Emergency Medicine, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada.
| | - Jonathan Sherbino
- McMaster Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
- Division of Education and Innovation, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Thomas Beardsley
- College of Medicine-Jacksonville, University of Florida, Gainesville, FL, USA
| | - James Bonz
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sara Gray
- Division of Emergency Medicine, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Andrew K Hall
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada
| | - Christopher Hicks
- Division of Emergency Medicine, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada
| | - Julie Kim
- Division of Emergency Medicine, Department of Medicine, Western University, London, ON, Canada
| | - George Mastoras
- Division of Emergency Medicine, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada
| | - Melissa McGowan
- Division of Emergency Medicine, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada
| | - Julian Owen
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sandra Monteiro
- McMaster Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
- Division of Education and Innovation, Department of Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
14
|
Meredith MA, Harrell KM, Foster KW, Edwards C, Puche AC. OpNotes and Clinical Exercises: Activities to Enhance the Clinical Context of the Preclerkship Anatomy Dissection Laboratory. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:912-916. [PMID: 36972133 DOI: 10.1097/acm.0000000000005216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
PROBLEM Despite numerous pedagogical approaches and technologies now available for medical gross anatomy, students can find it difficult to translate what occurs in a dissection laboratory into the context of clinical practice. APPROACH Using complementary and collaborative approaches at 2 different medical schools, Virginia Commonwealth University (VCU) and University of Maryland (UM), we designed and implemented a series of clinical activities in the preclerkship medical gross anatomy laboratory that directly link dissected structures to clinical procedures. These activities specifically direct students to perform simulated clinically related procedures on anatomic donors during laboratory dissection sessions. The activities are called OpNotes at VCU and Clinical Exercises at UM. Each activity in the VCU OpNotes requires about 15 minutes of group activity at the end of a scheduled laboratory and involves faculty to grade the student responses submitted via a web-based-assessment form. Each exercise in UM Clinical Exercises also requires about 15 minutes of group activity during the schedule laboratory but does not involve faculty to complete grading. OUTCOMES Cumulatively, the activities in OpNotes and Clinical Exercises both brought clinical context directly to anatomical dissections. These activities began in 2012 at UM and 2020 at VCU, allowing a multiyear and multi-institute development and testing of this innovative approach. Student participation was high, and perception of its effectiveness was almost uniformly positive. NEXT STEPS Future iterations of the program will work to assess the efficacy of the program as well as to streamline the scoring and delivery of the formative components. Collectively, we propose that the concept of executing clinic-like procedures on donors in anatomy courses is an effective means of enhancing learning in the anatomy laboratory while concurrently underscoring the relevance of basic anatomy to future clinical practice.
Collapse
Affiliation(s)
- M Alex Meredith
- M.A. Meredith is professor and past course director for medical gross anatomy, Department of Anatomy and Neurobiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: http://orcid.org/0000-0002-8081-6901
| | - Kelly M Harrell
- K.M. Harrell is associate professor and course director for medical gross anatomy, Department of Anatomy and Neurobiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: http://orcid.org/0000-0001-7849-9110
| | - Kenneth W Foster
- K.W. Foster is senior instructional technologist, Office of Faculty Affairs, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Cherie Edwards
- C. Edwards is instructor of educational research and evaluation, Office of Assessment, Evaluation and Scholarship, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Adam C Puche
- A.C. Puche is professor, vice chair, and content lead for all medical gross anatomy, Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland; ORCID: http://orcid.org/0000-0002-6847-1218
| |
Collapse
|
15
|
Klig JE, Kettyle WM, Kosowsky JM, Phillips, Jr. WR, Farrell SE, Hundert EM, Dalrymple JL, Goldhamer MEJ. A pilot clinical skills coaching program to reimagine remediation: a cohort study. MEDEDPUBLISH 2023; 13:29. [PMID: 37674590 PMCID: PMC10477753 DOI: 10.12688/mep.19621.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Background New approaches are needed to improve and destigmatize remediation in undergraduate medical education (UME). The COVID-19 pandemic magnified the need to support struggling learners to ensure competency and readiness for graduate medical education (GME). Clinical skills (CS) coaching is an underutilized approach that may mitigate the stigma of remedial learning. Methods A six-month CS coaching pilot was conducted at Harvard Medical School (HMS) as a destigmatized remedial learning environment for clerkship and post-clerkship students identified as 'at risk' based on objective structured clinical examinations (OSCE). The pilot entailed individual and group coaching with five faculty, direct bedside observation of CS, and standardized patient encounters with video review. Strengths-based coaching principles and appreciative inquiry were emphasized. Results Twenty-three students participated in the pilot: 14 clerkship students (cohort 1) and 9 post-clerkship students (cohort 2). All clerkship students (cohort 1) demonstrated sustained improvement in CS across three OSCEs compared to baseline: at pilot close, at 6-months post pilot, and at 21-24 months post-pilot all currently graduating students (10/10, 100%) passed the summative OSCE, an HMS graduation requirement. All post-clerkship students (cohort 2) passed the HMS graduation OSCE (9/9,100%). Feedback survey results included clerkship students (9/14; 64%) and post-clerkship students (7/9; 78%); all respondents unanimously agreed that individual coaching was "impactful to my clinical learning and practice". Faculty and leadership fully supported the pilot as a destigmatized and effective approach to remediation. Conclusion Remediation has an essential and growing role in medical schools. CS coaching for remedial learning can reduce stigma, foster a growth mindset, and support sustained progress for 'at risk' early clerkship through final year students. An "implementation template" with suggested tools and timelines can be locally adapted to guide CS coaching for UME remediation. The CS coaching pilot model is feasible and can be generalized to many UME programs.
Collapse
Affiliation(s)
- Jean E. Klig
- Massachusetts General Hospital, Boston, Massachusetts, 02114, USA
- Harvard Medical School, Boston, Massachusetts, 02115, USA
| | | | - Joshua M. Kosowsky
- Harvard Medical School, Boston, Massachusetts, 02115, USA
- Brigham and Women’s Hospital, Boston, Massachusetts, 02115, USA
| | - William R. Phillips, Jr.
- Harvard Medical School, Boston, Massachusetts, 02115, USA
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, 02115, USA
| | - Susan E. Farrell
- Harvard Medical School, Boston, Massachusetts, 02115, USA
- Brigham and Women’s Hospital, Boston, Massachusetts, 02115, USA
| | | | - John L. Dalrymple
- Harvard Medical School, Boston, Massachusetts, 02115, USA
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, 02115, USA
| | - Mary Ellen J. Goldhamer
- Massachusetts General Hospital, Boston, Massachusetts, 02114, USA
- Harvard Medical School, Boston, Massachusetts, 02115, USA
| |
Collapse
|
16
|
Hortsch M. Histology as a paradigm for a science-based learning experience: Visits by histology education spirits of past, present, and future. ANATOMICAL SCIENCES EDUCATION 2023; 16:372-383. [PMID: 36453080 DOI: 10.1002/ase.2235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/31/2022] [Accepted: 11/17/2022] [Indexed: 05/11/2023]
Abstract
The term "histology" was coined a little over 200 years ago and the subject has always relied on microscopy as its defining technology. Microscopy was and still is an essential approach for the description of cellular components and their arrangements in living organisms. For more than a century and a half, histology or microanatomy has also been part of the basic science education for biomedical students. Traditionally, it has been taught in two major components, a didactic transfer of information, either in a lecture or self-learning format, and in active-learning laboratory sessions. These two modes of histology instruction conform with the dual-processing theory of learning, one being more automatic and depending mainly on rote memorization, whereas the other is analytical, requiring more advanced reasoning skills. However, these two components of histology education are not separate and independent, but rather complementary and part of a multi-step learning process that encourages a scientific analysis of visual information and involves higher-level learning skills. Conventional, as well as modern electronic instruction methods (e-learning) have been used in complementary ways to support the integrated succession of individual learning steps as outlined in this manuscript. However, as recent curricular reforms have curtailed instructional time, this traditional format of teaching histology is no longer sustainable and a reflective reassessment of the role of histology in modern biomedical education is a timely necessity.
Collapse
Affiliation(s)
- Michael Hortsch
- Department of Cell and Developmental Biology, University of Michigan Medical School, Michigan, Ann Arbor, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Michigan, Ann Arbor, USA
| |
Collapse
|
17
|
Al Mousa AM, Alhubail FM, Almulhim M, AlBeladi BA, Almulhim NA, Almulhim AA, Algouf IA, Khan AS. Electrocardiogram Interpretation Competency of Medical Interns in Saudi Arabia: A Cross-Sectional Study. Cureus 2023; 15:e37557. [PMID: 37193433 PMCID: PMC10183095 DOI: 10.7759/cureus.37557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/18/2023] Open
Abstract
Objective To determine the competence of medical interns in Saudi Arabia in interpreting common ECG abnormalities, explore limitations, and facilitate solutions to the development of ECG interpretation skills in Saudi Arabia. Methods This cross-sectional study was conducted from 11 June 2022 to 3 November 2022 using the convenience stratified sampling technique among 373 medical interns (54.4% male and 45.6% female) in 15 medical colleges within Saudi Arabia. Results Almost all (91.7%) of the participants recognized the basic ECG elements, as they correctly identified normal ECG patterns. The most well-understood ECG pathologies were ventricular fibrillation, atrial fibrillation, and acute myocardial infarction, which were accurately interpreted by 69.2%, 67.8%, and 61.9% of the participants, respectively. The least understood ECG result was a pathological Q wave, which only 20.9% recognized. Most (63.5%) participants attributed their challenges in ECG interpretation to their inadequate training in college, and 57.4% of them stated that practical case-based training could best facilitate the improvement of their skills in ECG interpretation. Conclusion Most of the participants showed unsatisfactory performance in ECG interpretation. Despite their completion of advanced cardiac life support courses, their overall performance did not improve significantly. Most of them believed that their colleges did not adequately train them to read ECGs. Thus, a majority think case-based training is a key strategy for improving their ECG interpretation skills.
Collapse
Affiliation(s)
- Ali M Al Mousa
- Internal Medicine Department, College of Medicine, King Faisal University, Alahsa, SAU
| | - Fatimah M Alhubail
- Internal Medicine Department, College of Medicine, King Faisal University, Alahsa, SAU
| | - Mohannad Almulhim
- Internal Medicine Department, College of Medicine, King Faisal University, Alahsa, SAU
| | - Baneen A AlBeladi
- Clinical Pharmacy Department, College of Clinical Pharmacy, King Faisal University, Alahsa, SAU
| | - Nasser A Almulhim
- Internal Medicine Department, College of Medicine, King Faisal University, Alahsa, SAU
| | - Abdullah A Almulhim
- Internal Medicine Department, College of Medicine, King Faisal University, Alahsa, SAU
| | - Ibtisam A Algouf
- Internal Medicine Department, College of Medicine, King Faisal University, Alahsa, SAU
| | - Abdul Sattar Khan
- Family and Community Medicine Department, College of Medicine, King Faisal University, Alahsa, SAU
| |
Collapse
|
18
|
Ue F, Kaminski M. Point: Routine prerounding with patients has significant costs, negligible benefits. J Hosp Med 2023; 18:458-459. [PMID: 36879418 DOI: 10.1002/jhm.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 10/21/2022] [Accepted: 02/20/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Frances Ue
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, USA
- Faculty of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Martin Kaminski
- Faculty of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Section of Hospital Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
19
|
Excellence in Pediatric Physical Therapy Education: Recommendations and Action Items. Pediatr Phys Ther 2023; 35:260-267. [PMID: 36854111 DOI: 10.1097/pep.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
PURPOSE This special communication identifies evidence-based recommendations and offers action items to facilitate the uptake of new knowledge from the National Study of Excellence in Pediatric Physical Therapy Education (NSE-Peds). SUMMARY OF KEY POINTS The NSE-Peds identified a conceptual framework consisting of 4 key dimensions and associated elements that dynamically interact to prepare future physical therapists to meet the needs of society. The conceptual framework serves as the Knowledge Creation component of the knowledge to action (KTA) framework, but translation into practice requires the Action Cycle, the second component of the KTA framework. Recommendations and action items provide tangible products derived from the NSE-Peds conceptual framework for application in the Action Cycle. CONCLUSIONS Using the KTA framework, implementation of the recommendations at the level of the individual, program, and organization should enhance pediatric physical therapy education and ultimately physical therapy care provided to children and families.
Collapse
|
20
|
Grant R, McMurtry A, Archibald D. Mapping Health Professions Education: Using Complexity Science to Make Sense of Learning Through Electronic Consultations. MEDICAL SCIENCE EDUCATOR 2023; 33:233-242. [PMID: 37008438 PMCID: PMC10060472 DOI: 10.1007/s40670-023-01730-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 06/19/2023]
Abstract
Phenomena studied within health professions education are often complex and multifaceted. This article describes a complexity science-informed theoretical framework that was developed for exploring how electronic consultations support learning among primary care providers, as well as within the larger organizations or systems in which they practice. This framework enables researchers to investigate learning occurring simultaneously at multiple levels (including individuals and social groups), without simplistically conflating levels or theories. The various levels of learning and associated theories are illustrated using examples from electronic consultations. This complexity science-inspired framework can be used for studying learning in complex, multilayered systems.
Collapse
Affiliation(s)
- Rachel Grant
- Faculty of Education, University of Ottawa, Ottawa, ON Canada
| | - Angus McMurtry
- Faculty of Education, University of Ottawa, Ottawa, ON Canada
| | - Douglas Archibald
- Faculty of Education, University of Ottawa, Ottawa, ON Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
- Bruyère Research Institute, Ottawa, ON Canada
| |
Collapse
|
21
|
Lockwood LZ, Williams JTB, Tanverdi M, Barry Seltz L. A Qualitative Study of Pediatric Residents' Experiences at Morning Report. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231211467. [PMID: 37942024 PMCID: PMC10629304 DOI: 10.1177/23821205231211467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/09/2023] [Indexed: 11/10/2023]
Abstract
Objectives Morning Report is a prevalent classroom learning activity in residency programs. Yet, its contribution to resident education remains unclear. Our objective was to explore pediatric residents' perceptions of the purpose of Morning Report as well as their experiences at Morning Report both as learners and resident presenters. Methods We performed a qualitative study with a grounded theory approach using semi-structured focus groups of pediatric residents (November 2016-July 2017) from a large academic health center. We analyzed data with the constant comparative method, generating codes using an iterative approach and collecting data until reaching saturation. We identified major themes and resolved disagreements by consensus. Results Twenty-six residents participated in five focus groups. Data analysis yielded four themes: Morning Report is Multipurpose, Socialization and Engagement Influence the Learning Environment, Potential for Emotional Discomfort, and Barriers to Prioritizing Morning Report Attendance. Residents felt the primary purpose of Morning Report was acquiring medical knowledge, but also acknowledged Morning Report's added benefits of providing an opportunity for socialization and a mental reprieve before work rounds. Residents felt Morning Report was educational when engaged in interactive discussion; however, it was challenging to meet the differing needs in this mixed learner level format. Some resident learners were hesitant to participate due to fears of being judged, and some resident presenters perceived a need to be topic experts. Clinical responsibilities and exhaustion following busy service rotations often precluded Morning Report attendance. Conclusion Pediatric residents described numerous purposes of Morning Report, including opportunities for valuable learning. Self-perceived learning was positively influenced by engagement and a sense of connection and challenged by emotional discomfort at times. Future work can explore how to best promote engagement and foster a safe learning environment.
Collapse
Affiliation(s)
- Laura Z. Lockwood
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua T. B. Williams
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatrics, Ambulatory Care Services, Denver Health Medical Center, Denver, CO, USA
- Center for Health Systems Research, Denver Health, Denver, CO, USA
| | - Melisa Tanverdi
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - L. Barry Seltz
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
22
|
Pusic MV, Birnbaum RJ, Thoma B, Hamstra SJ, Cavalcanti RB, Warm EJ, Janssen A, Shaw T. Frameworks for Integrating Learning Analytics With the Electronic Health Record. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2023; 43:52-59. [PMID: 36849429 PMCID: PMC9973448 DOI: 10.1097/ceh.0000000000000444] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The information systems designed to support clinical care have evolved separately from those that support health professions education. This has resulted in a considerable digital divide between patient care and education, one that poorly serves practitioners and organizations, even as learning becomes ever more important to both. In this perspective, we advocate for the enhancement of existing health information systems so that they intentionally facilitate learning. We describe three well-regarded frameworks for learning that can point toward how health care information systems can best evolve to support learning. The Master Adaptive Learner model suggests ways that the individual practitioner can best organize their activities to ensure continual self-improvement. The PDSA cycle similarly proposes actions for improvement but at a health care organization's workflow level. Senge's Five Disciplines of the Learning Organization, a more general framework from the business literature, serves to further inform how disparate information and knowledge flows can be managed for continual improvement. Our main thesis holds that these types of learning frameworks should inform the design and integration of information systems serving the health professions. An underutilized mediator of educational improvement is the ubiquitous electronic health record. The authors list learning analytic opportunities, including potential modifications of learning management systems and the electronic health record, that would enhance health professions education and support the shared goal of delivering high-quality evidence-based health care.
Collapse
|
23
|
Carraccio C, Lentz A, Schumacher DJ. "Dismantling Fixed Time, Variable Outcome Education: Abandoning 'Ready or Not, Here they Come' is Overdue". PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:68-75. [PMID: 36937800 PMCID: PMC10022540 DOI: 10.5334/pme.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/28/2023] [Indexed: 05/05/2023]
Abstract
Two decades after competency-based medical education appeared in the lexicon of medical educators, the community continues to struggle with realizing its full potential. The implementation of the time variable, fixed outcome component has languished based on complexity compounded by resistance to change. Learners continue to transition from medical school to residency, and then practice, primarily based on time rather than having achieved the ability to meet the needs of the patient populations they will serve. Only those few who demonstrate glaring deficiencies do not graduate. The authors urge the medical education community to move from the current fixed time path of medical education toward the implementation of a true continuum of time variable, fixed outcome education, training, and deliberate practice. The latter is defined by purposeful learning, coaching, feedback, and repetition on the path to achieving and maintaining expertise. The opportunities afforded by such a time-variable, fixed outcome approach include: 1) development of a career long growth mindset, 2) ability to address evolving population health needs and careers within the context of one's practice, and 3) continual improvement of care quality and outcomes for patients on the journey towards expertise for providers.
Collapse
Affiliation(s)
| | | | - Daniel J. Schumacher
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| |
Collapse
|
24
|
Pusic MV, Hall E, Billings H, Branzetti J, Hopson LR, Regan L, Gisondi MA, Cutrer WB. Educating for adaptive expertise: case examples along the medical education continuum. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:1383-1400. [PMID: 36414880 DOI: 10.1007/s10459-022-10165-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
Adaptive expertise represents the combination of both efficient problem-solving for clinical encounters with known solutions, as well as the ability to learn and innovate when faced with a novel challenge. Fostering adaptive expertise requires careful approaches to instructional design to emphasize deeper, more effortful learning. These teaching strategies are time-intensive, effortful, and challenging to implement in health professions education curricula. The authors are educators whose missions encompass the medical education continuum, from undergraduate through to organizational learning. Each has grappled with how to promote adaptive expertise development in their context. They describe themes drawn from educational experiences at these various learner levels to illustrate strategies that may be used to cultivate adaptive expertise.At Vanderbilt University School of Medicine, a restructuring of the medical school curriculum provided multiple opportunities to use specific curricular strategies to foster adaptive expertise development. The advantage for students in terms of future learning had to be rationalized against assessments that are more short-term in nature. In a consortium of emergency medicine residency programs, a diversity of instructional approaches was deployed to foster adaptive expertise within complex clinical learning environments. Here the value of adaptive expertise approaches must be balanced with the efficiency imperative in clinical care. At Mayo Clinic, an existing continuous professional development program was used to orient the entire organization towards an adaptive expertise mindset, with each individual making a contribution to the shift.The different contexts illustrate both the flexibility of the adaptive expertise conceptualization and the need to customize the educational approach to the developmental stage of the learner. In particular, an important benefit of teaching to adaptive expertise is the opportunity to influence individual professional identity formation to ensure that clinicians of the future value deeper, more effortful learning strategies throughout their careers.
Collapse
Affiliation(s)
- Martin V Pusic
- Division of Pediatric Emergency Medicine, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, CH3306, USA.
| | - Elissa Hall
- Learning and Technology Innovation, Education Science, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Heather Billings
- Academy of Educational Excellence, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | - Laura R Hopson
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Linda Regan
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A Gisondi
- The Precision Education and Assessment Research Lab, Department of Emergency Medicine, Stanford School of Medicine, Palo Alto, CA, USA
| | - William B Cutrer
- Undergraduate Medical Education, Vanderbilt University School of Medicine, Nashville, TN, USA
| |
Collapse
|
25
|
Branzetti J, Commissaris C, Croteau C, Ehmann MR, Gisondi MA, Hopson LR, Lai KYF, Regan L. The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1691-1698. [PMID: 35612927 DOI: 10.1097/acm.0000000000004751] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Adaptive expertise (AE) has been identified as a critical trait to cultivate in future physicians. The 4-phase master adaptive learner (MAL) conceptual model describes the learning skills and behaviors necessary to develop AE. Though prior work has elucidated skills and behaviors used by MALs in the initial planning phase of learning, most resident learners are not thought to be MALs. In this study, the authors investigated how these majority "typical" learners develop AE by exploring the strategies they used in the planning phase of learning. METHOD Participants were resident physicians at graduate medical education (GME) training programs located at 4 academic medical centers in the United States. Participants participated in semistructured individual interviews in 2021, and interview transcripts were analyzed using constant comparative analysis of grounded theory. RESULTS Fourteen subjects representing 8 specialties were interviewed, generating 152 pages of transcripts for analysis. Three themes were identified: "Typical" learners were challenged by the transition from structured undergraduate medical education learning to less-structured GME learning, lacked necessary skills to easily navigate this transition, and relied on trial and error to develop their learning skills. CONCLUSIONS Participants used trial and error to find learning strategies to help them manage the systemic challenges encountered when transitioning from medical school to residency. The success (or failure) of these efforts was tied to learners' efficacy with the self-regulated learning concepts of agency, metacognitive goal setting, and motivation. A conceptual model is provided to describe the impact of these factors on residents' ability to be adaptive learners, and actionable recommendations are provided to help educators' efforts to foster adaptive learning skills and behaviors. These findings also provided valuable evidence of validity of the MAL model that has thus far been lacking.
Collapse
Affiliation(s)
- Jeremy Branzetti
- J. Branzetti is residency director, Emergency Medicine Residency, and assistant professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York; ORCID: https://orcid.org/0000-0002-2397-0566
| | - Carolyn Commissaris
- C. Commissaris is emergency medicine residency assistant program director and clinical instructor, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0002-7099-4851
| | - Charlotte Croteau
- C. Croteau is a third-year resident, NYU/Bellevue Emergency Medicine Residency, New York, New York
| | - Michael R Ehmann
- M.R. Ehmann is emergency medicine associate residency program director and assistant professor of emergency medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; ORCID: https://orcid.org/0000-0002-8093-7623
| | - Michael A Gisondi
- M.A. Gisondi is associate professor and vice chair of education, Department of Emergency Medicine, Precision Education and Assessment Research Lab, Stanford University School of Medicine, Stanford, California; ORCID: https://orcid.org/0000-0002-6800-3932
| | - Laura R Hopson
- L.R. Hopson is associate chair for education and professor, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: http://orcid.org/0000-0003-1745-0836
| | - Krystal Ya-Fong Lai
- K.Y.-F. Lai is a first-year resident, University of Texas Southwestern Internal Medicine Residency, Dallas, Texas
| | - Linda Regan
- L. Regan is emergency medicine residency program director, vice chair for education, and associate professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; ORCID: https://orcid.org/0000-0003-0390-4243
| |
Collapse
|
26
|
van Diggele C, Lane S, Roberts C. Student Interprofessional Facilitator Training (SIFT) program: building capacity in clinical education leadership. BMC MEDICAL EDUCATION 2022; 22:665. [PMID: 36071493 PMCID: PMC9451648 DOI: 10.1186/s12909-022-03725-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND While there are many teacher training programs for health professional students, few are interprofessional, and few integrate assessment and feedback prior to participation as peer teachers. In 2021, The Student Interprofessional Facilitator Training (SIFT) program was developed to allow senior students, already trained in peer teaching, to revise, build on, and practice their newly acquired skills in an interprofessional context. The aim of this study was to explore participant perception and performance, and the contextual factors that influence student aspirations as clinical teachers. METHODS Alumni of the 2021 Peer Teacher Training program (n = 74) were invited to participate in the SIFT program. Those who participated were invited to attend individual semi-structured interviews. Thematic analysis was used to code and categorise data into themes, using Communities of Practice as a conceptual framework. Skills in interprofessional facilitation were observed, assessed and students were provided with individual feedback. Assessment data were analysed using descriptive statistics. RESULTS Sixteen students from six disciplines joined the SIFT program, and 13/16 (81%) completed. Students were from medicine, nursing, diagnostic radiography, medical imaging, dentistry and speech pathology. Students reported an increased recognition of teaching as a learned skill, development of clinician identity formation as educators, development of interprofessional communication skills, increased awareness of the roles of other health professions, and an increased understanding of leadership. Participants expressed a desire for additional opportunities for interprofessional networking and peer teaching. A good level of competence in facilitation skills was reached by participants. CONCLUSION The SIFT program provided a sustainable framework for health professional students to develop and evidence their teaching and leadership skills in an interprofessional context. This study highlighted the important role of observation, assessment and feedback in student teacher training programs. The process of clear assessment guidelines, direct observation with feedback from supervisors provided a way to ensure quality improvement in peer teaching. The SIFT program will help to build capacity of interprofessional programs where large numbers of teachers are required for small group teaching. The next step will be to ensure a variety of opportunities within interprofessional contexts, and with face-to-face engagement.
Collapse
Affiliation(s)
- Christie van Diggele
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Stuart Lane
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Chris Roberts
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
27
|
Abraham K, Green-Wilson J, Hartley GW, Deusinger S, Altenburger P, Blackinton M, Byl N, Nordstrom T, Tschoepe B. Master Adaptive Learning as a Framework for Physical Therapist Professional Education: A Call to Action. Phys Ther 2022; 102:6586186. [PMID: 35575908 DOI: 10.1093/ptj/pzac064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/09/2022] [Accepted: 04/28/2022] [Indexed: 11/12/2022]
Affiliation(s)
| | | | | | - Susan Deusinger
- Washington University School of Medicine, St Louis, Missouri, USA
| | | | | | - Nancy Byl
- University of California, San Francisco, California, USA
| | | | | |
Collapse
|
28
|
Schumacher DJ, Michelson C, Winn AS, Turner DA, Elshoff E, Kinnear B. Making prospective entrustment decisions: Knowing limits, seeking help and defaulting. MEDICAL EDUCATION 2022; 56:892-900. [PMID: 35263474 DOI: 10.1111/medu.14797] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Many studies focused on entrustment have not considered prospective entrustment decisions, where clinical competency and entrustment committees determine how much supervision trainees will require in the future for tasks occurring in not completely known contexts. The authors sought to explore factors that influence and determine prospective entrustment decisions made by members of such committees in graduate medical education (GME) and undergraduate medical education (UME). METHODS The authors conducted a constructivist grounded theory study with 23 faculty participants from GME and UME clinical competency and entrustment committees in the United States between October 2020 and March 2021. Interviews sought to explore factors and considerations participants weigh in making prospective entrustment decisions about trainees. Data collection and analysis occurred in an iterative fashion, ensuring constant comparison. Theoretical sampling was used to confirm, disconfirm and elaborate on the evolving results. RESULTS Trainees' ability to know limits and seek help is the foundation of participants' prospective entrustment decision making. Most participants, however, describe a presumption of trainee readiness to progress and describe commonly making default prospective entrustment decisions unless 'red flags' in performance are present. Although participants desire sufficient and trusted data about trainee performance to inform decisions, they often lack it. Finally, the perceived permanence and consequences of prospective entrustment decisions influence how participants weigh other factors contributing to prospective entrustment decisions. CONCLUSION Trainees' ability to know limits and seek help appears to be the foundation of prospective entrustment decision making. Training programmes should strive to collect and employ robust data supporting and questioning the presence of these attributes.
Collapse
Affiliation(s)
- Daniel J Schumacher
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Catherine Michelson
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ariel S Winn
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Turner
- American Board of Pediatrics, Chapel Hill, North Carolina, USA
| | | | - Benjamin Kinnear
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
29
|
Shen J, Qi H, Chen Y, Mei R, Sun C, Wang Z. Incorporating modified team-based learning into a flipped basic medical laboratory course: impact on student performance and perceptions. BMC MEDICAL EDUCATION 2022; 22:608. [PMID: 35933354 PMCID: PMC9356488 DOI: 10.1186/s12909-022-03676-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/02/2022] [Indexed: 05/09/2023]
Abstract
BACKGROUND Basic medical laboratory courses (BMLCs) play an essential role in medical education and offer several benefits to students. Although various student-centered and active learning strategies have been increasingly incorporated into medical education, their applications in BMLCs are limited. This paper aimed to explore the educational effects of a flipped classroom (FC) combined with team-based learning (TBL) strategy in BMLCs at Zhejiang University School of Medicine. METHODS Four hundred eight 3rd-Year medical students were assigned to either the FC-TBL group (n = 235) or the FC group (n = 173) to complete three experiments on the respiration block of BMLCs. The two groups' immediate and long-term academic performance were compared, and the FC-TBL students' perceptions of different instructional strategies were surveyed. RESULTS Students in the FC-TBL group scored higher on the immediate post-tests after class and higher on the final exams in two of the three experiment sessions. They preferred FC-TBL to FC for its higher engagement, more feedback, and better learning environment. Students felt the FC with TBL blended instructional strategy stimulated their interest in learning and deep thinking. CONCLUSIONS Compared with the FC group, students in the FC-TBL group improved academic performance and had a more positive experience overall. Our findings support the feasibility and advantage of the flipped classroom with team-based learning as a blended learning strategy in the BMLC curriculum.
Collapse
Affiliation(s)
- Jing Shen
- Department of Pathology and Pathophysiology, and Department of Medical Oncology of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China.
| | - Hongyan Qi
- Department of Pathology and Pathophysiology, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Yingying Chen
- Department of Pathology and Pathophysiology, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Ruhuan Mei
- Experimental Teaching Center of Basic Medicine, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Cencen Sun
- Experimental Teaching Center of Basic Medicine, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Zhengyang Wang
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| |
Collapse
|
30
|
Nordstrom T, Jensen GM, Altenburger P, Blackinton M, Deusinger S, Hack L, Patel RM, Tschoepe B, VanHoose L. Crises as the Crucible for Change in Physical Therapist Education. Phys Ther 2022; 102:6585155. [PMID: 35554600 DOI: 10.1093/ptj/pzac055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 12/15/2021] [Accepted: 02/17/2022] [Indexed: 11/15/2022]
Abstract
This Perspective issues a challenge to physical therapists to reorient physical therapist education in ways that directly address the crises of COVID-19 and systemic racism. We advocate that professional education obligates us to embrace the role of trusteeship that demands working to meet society's needs by producing graduates who accept their social and moral responsibilities as agents and advocates who act to improve health and health care. To achieve this, we must adopt a curriculum philosophy of social reconstruction and think more deeply about the why and how of learning. Currently, health professions education places strong emphasis on habits of head (cognitive knowledge) and hand (clinical skills) and less focus on habits of heart (professional formation). We believe that habits of heart are the essential foundations of the humanistic practice needed to address health inequities, find the moral courage to change the status quo, and address imbalances of power, privilege, and access. A social reconstruction orientation in physical therapist education not only places habits of heart at the center of curricula, but it also requires intentional planning to create pathways into the profession for individuals from underrepresented groups. Adopting social reconstructionism begins with a faculty paradigm shift emphasizing the learning sciences, facilitating learning, metacognition, and development of a lifelong master adaptive learner. Achieving this vision depends not only on our ability to meet the physical therapy needs of persons with COVID-19 and its sequalae but also on our collective courage to address injustice and systemic racism. It is imperative that the physical therapy community find the moral courage to act quickly and boldly to transform DPT education in ways that enable graduates to address the social determinants of health and their systemic and structural causes that result in health disparities. To succeed in this transformation, we are inspired and strengthened by the example set by Geneva R. Johnson, who has never wavered in recognizing the power of physical therapy to meet the needs of society.
Collapse
Affiliation(s)
- Terry Nordstrom
- Samuel Merritt University, Department of Physical Therapy, Oakland, California, USA
| | - Gail M Jensen
- Creighton University, Department of Physical Therapy, School of Pharmacy and Health Professions, Omaha, Nebraska, USA
| | - Peter Altenburger
- Indiana University, Department of Physical Therapy, Indianapolis, Indiana, USA
| | - Mary Blackinton
- Rehab Essentials, enTandem DPT, Columbia Falls, Montana, USA
| | - Susan Deusinger
- Washington University in St Louis, Program in Physical Therapy, St Louis, Missouri, USA
| | - Laurita Hack
- Temple University, Department of Physical Therapy, Philadelphia, Pennsylvania, USA
| | - Rupal M Patel
- Texas Woman's University, School of Physical Therapy, Houston, Texas, USA
| | - Barbara Tschoepe
- Educational Consultant and Physical Therapy Learning Institute, Boulder, Colorado, USA
| | - Lisa VanHoose
- Ujima Institute and Foundation, Monroe, Louisiana, USA
| |
Collapse
|
31
|
Reimagining the Clinical Competency Committee to Enhance Education and Prepare for Competency-Based Time-Variable Advancement. J Gen Intern Med 2022; 37:2280-2290. [PMID: 35445932 PMCID: PMC9021365 DOI: 10.1007/s11606-022-07515-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/25/2022] [Indexed: 12/01/2022]
Abstract
Assessing residents and clinical fellows is a high-stakes activity. Effective assessment is important throughout training so that identified areas of strength and weakness can guide educational planning to optimize outcomes. Assessment has historically been underemphasized although medical education oversight organizations have strengthened requirements in recent years. Growing acceptance of competency-based medical education and its logical extension to competency-based time-variable (CB-TV) graduate medical education (GME) further highlights the importance of implementing effective evidence-based approaches to assessment. The Clinical Competency Committee (CCC) has emerged as a key programmatic structure in graduate medical education. In the context of launching a multi-specialty pilot of CB-TV GME in our health system, we have examined several program's CCC processes and reviewed the relevant literature to propose enhancements to CCCs. We recommend that all CCCs fulfill three core goals, regularly applied to every GME trainee: (1) discern and describe the resident's developmental status to individualize education, (2) determine readiness for unsupervised practice, and (3) foster self-assessment ability. We integrate the literature and observations from GME program CCCs in our institutions to evaluate how current CCC processes support or undermine these goals. Obstacles and key enablers are identified. Finally, we recommend ways to achieve the stated goals, including the following: (1) assess and promote the development of competency in all trainees, not just outliers, through a shared model of assessment and competency-based advancement; (2) strengthen CCC assessment processes to determine trainee readiness for independent practice; and (3) promote trainee reflection and informed self-assessment. The importance of coaching for competency, robust workplace-based assessments, feedback, and co-production of individualized learning plans are emphasized. Individual programs and their CCCs must strengthen assessment tools and frameworks to realize the potential of competency-oriented education.
Collapse
|
32
|
McClintock AH, Fainstad T. Growth, Engagement, and Belonging in the Clinical Learning Environment: the Role of Psychological Safety and the Work Ahead. J Gen Intern Med 2022; 37:2291-2296. [PMID: 35710656 PMCID: PMC9296742 DOI: 10.1007/s11606-022-07493-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
Abstract
Psychological safety is the perception that an environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of being shamed, blamed, or ignored. The presence of psychological safety has been associated with improved team learning and innovation, leader inclusivity, and team members' sense of belonging. In medical education, psychological safety has additional benefits: it allows learners to be present in the moment and to focus on the tasks at hand, and reduces trainee focus on image. Several key features of psychologically safe environments have already been described, including the presence of high-quality relationships, the absence of social positioning, a learner-driven and flexible learning agenda, the lack of formal assessment, and time for debriefing. However, many of the structures and cultural traditions in medical education are in clear opposition to these features. This paper describes the current barriers to psychological safety in medical education, and sets out an agenda for change. In accordance with benefits seen in other sectors, we anticipate that an emphasis on relationships and psychological safety will support the learning, inclusion, and success of medical trainees.
Collapse
Affiliation(s)
- Adelaide H McClintock
- Department of Medicine, Division of General Internal Medicine, University of Washington School of Medicine, 4245 Roosevelt Way NE, Box 354765, Seattle, WA, 98107, USA.
| | - Tyra Fainstad
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
33
|
Afolabi TM, Pogge EK, Early NK, Larson S, Stein J, Hanson L, Storjohann T, Raney E, Davis LE. Evaluating the impact of integrating SMART goal setting in preceptor development using the Habits of Preceptors Rubric. Am J Health Syst Pharm 2022; 79:1180-1191. [PMID: 35368054 DOI: 10.1093/ajhp/zxac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The impact of goal setting in pharmacy preceptor development was evaluated using the Habits of Preceptors Rubric (HOP-R), a criterion-referenced assessment developed to assess, quantify, and demonstrate growth across 11 preceptor habits. METHODS This study retrospectively evaluated initial and follow-up survey responses from the 2019-2020 Clinician Educators Program cohort at Midwestern University College of Pharmacy, Glendale Campus. Enrollees in this teaching and learning curriculum (TLC) were invited to assess their precepting habits using the HOP-R after attending the first seminar and again toward the end of the longitudinal program. Using online surveys, participants rated their precepting capabilities as developing, proficient, accomplished, or master level for each habit. In the initial survey, each participant selected a habit of focus for deliberate development and established an individualized goal using the specific, measurable, achievable, relevant, and time-bound (SMART) framework. In the follow-up survey, participants indicated their satisfaction with and progress toward accomplishing their precepting goal. RESULTS Initial survey results from 55 study participants identified developing as the most frequently self-reported habit level (53%; n = 605 ratings), while master was the least frequently reported (1%). In the follow-up assessment, accomplished (45%) was the most frequently self-reported habit level, while master (5%) remained the least reported. The cohort reported a median progress in SMART goal accomplishment of 69% (range, 12% to 100%; n = 54). CONCLUSION Preceptors and resident pharmacists reported perceived advancement in precepting capabilities within the conceptual framework of the HOP-R encompassing both their self-selected habit of focus and adjacent habits while enrolled in a TLC. SMART goals facilitated qualitative and quantitative assessment of development.
Collapse
Affiliation(s)
- Titilola M Afolabi
- Department of Pharmacy, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Elizabeth K Pogge
- Department of Pharmacy, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Nicole K Early
- Department of Pharmacy, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Suzanne Larson
- Office of Experiential Education, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Jane Stein
- Office of Experiential Education, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Laura Hanson
- Office of Experiential Education, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Tara Storjohann
- Department of Pharmacy, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Erin Raney
- Department of Pharmacy, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| | - Lindsay E Davis
- Department of Pharmacy, Midwestern University College of Pharmacy, Glendale Campus, Glendale, AZ, USA
| |
Collapse
|
34
|
Boscardin CK, Bullock J, O'Sullivan P, Hauer K. Profiles for Success: Examining the Relationship between Student Profiles and Clerkship Performance Using Latent Profile Analysis. TEACHING AND LEARNING IN MEDICINE 2022; 34:145-154. [PMID: 35349389 DOI: 10.1080/10401334.2021.1937180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 06/14/2023]
Abstract
PHENOMENON Learning is a complex phenomenon in which learners can vary in their learning orientation, learning approaches, and perception of the learning environment. Learners may be characterized as mastery oriented or performance oriented, and this learning orientation can influence their learning approaches, such as whether to seek feedback or ask for help. The learning environment includes institutional assessment policies and informal interactions that emphasize outcomes and differentiation among students. When learners perceive the learning environment as performance oriented, they feel competition from other learners and fear negative feedback. This complex interplay of learning orientation, its influence on feedback-seeking behavior, and the environmental influence and reinforcement of both can be captured through learner profiles. APPROACH In this multi-institutional cross-sectional survey study of students from six U.S. medical schools, we investigated learner profiles that characterize how these domains manifest together across individual learners. We then determined how these profiles are associated with students' clerkship grades. Measures included the Patterns of Adaptive Learning for learning orientation, self-reports for learning approaches, and perceptions of the learning environment. We used latent profile analysis to cluster students who share common characteristics around orientation, behavior, and environment. The relationship between these profiles and the percentage of honors earned was examined using multiple regression analysis. FINDINGS We found four distinct learner profiles within 666 of 974 (68%) analyzable responses: (1) performance oriented with negative perceptions of environment, (2) mastery oriented with desirable learning approaches, (3) "average" group, and (4) mastery orientation only. Profile 1 (M = 39%) and Profile 4 (M = 38%) students received fewer clerkship honors compared with other profiles. Profile 2 students earned a significantly higher percentage of honors grades (M = 54%) compared with other students. Profile 3 students (average group) earned the second highest percentage of honors (M = 46%). Effect sizes comparing the percentage of honors varied from 0.32 to 0.65, indicating medium to large differences. INSIGHTS The highest performers, as measured by clerkship honors grades, were mastery oriented, perceived a more positive learning environment, and were comfortable asking questions and seeking feedback for their learning. The lowest performing students were performance oriented and had negative perceptions of their learning environments. Contrary to previous findings, we found that the relationship between mastery orientation and learning approaches is not unidirectional but rather seems to be mediated by perceptions of the learning environment.
Collapse
Affiliation(s)
- Christy K Boscardin
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Justin Bullock
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Patricia O'Sullivan
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Karen Hauer
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
35
|
Rivard SJ, Kemp MT, Evans J, Sandhu G. Resident Perceptions of Faculty Behaviors Promoting Learner Operative Skills and Autonomy. JOURNAL OF SURGICAL EDUCATION 2022; 79:431-440. [PMID: 34758932 DOI: 10.1016/j.jsurg.2021.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To better understand the resident perceived faculty factors associated with the promotion of resident operative skill and autonomy DESIGN: Qualitative retrospective analysis utilizing anonymous open-ended comments from residents on department of surgery faculty teaching evaluations and cross references them to observed faculty entrustment scores SETTING: Single tertiary midwestern allopathic academic medical center using data obtained between January 2016-August 2019 PARTICIPANTS: Forty-six resident and fourteen faculty surgeons from general, plastic, thoracic, and vascular surgery sections. RESULTS Themes of personal traits, the working environment created, and teaching techniques employed were identified across resident promoting attendings and resident limiting attendings. Promoting attendings employed preoperative goal setting, increased operative autonomy, and postoperative feedback while creating environments conducive to learning by promoting teamwork and collaboration. Alternatively, limiting attendings used more ineffective teaching techniques including micromanaging, lack of delegation, and treating residents as observers. Additionally, trainees described these operating room environments as stressful and strained. CONCLUSIONS Qualitative analysis of resident teaching evaluations of attending surgeons highlights the importance of relationships between learner and teacher, the learning environment, and teaching techniques. Continuous professional development programs centered on entrustment and promoting behaviors have the potential to disseminate strategies to enhance educator skills among surgeons.
Collapse
Affiliation(s)
| | - Michael T Kemp
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Julie Evans
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Gurjit Sandhu
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| |
Collapse
|
36
|
Schumacher DJ, Teunissen PW, Kinnear B, Driessen EW. Assessing trainee performance: ensuring learner control, supporting development, and maximizing assessment moments. Eur J Pediatr 2022; 181:435-439. [PMID: 34286373 DOI: 10.1007/s00431-021-04182-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/28/2022]
Abstract
In this article, the authors provide practical guidance for frontline supervisors' efforts to assess trainee performance. They focus on three areas. First, they argue the importance of promoting learner control in the assessment process, noting that providing learners agency and control can shift the stakes of assessment from high to low and promote a safe environment that facilitates learning. Second, they posit that assessment should be used to support continued development by promoting a relational partnership between trainees and supervisors. This partnership allows supervisors to reinforce desirable aspects of performance, provide real-time support for deficient areas of performance, and sequence learning with the appropriate amount of scaffolding to push trainees from competence (what they can do alone) to capability (what they are able to do with support). Finally, they advocate the importance of optimizing the use of written comments and direct observation while also recognizing that performance is interdependent in efforts to maximize assessment moments.Conclusion: Using best practices in trainee assessment can help trainees take next steps in their development in a learner-centered partnership with clinical supervisors. What is Known: • Many pediatricians are asked to assess the performance of medical students and residents they work with but few have received formal training in assessment. What is New: • This article presents evidence-based best practices for assessing trainees, including giving trainees agency in the assessment process and focusing on helping trainees take next steps in their development.
Collapse
Affiliation(s)
- Daniel J Schumacher
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Pim W Teunissen
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences and Gynecologist, Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Benjamin Kinnear
- Internal Medicine and Pediatrics, Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erik W Driessen
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
37
|
Effects of Gamification on the Benefits of Student Response Systems in Learning of Human Anatomy: Three Experimental Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413210. [PMID: 34948818 PMCID: PMC8702114 DOI: 10.3390/ijerph182413210] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
Abstract
This paper presents three experiments to assess the impact of gamifying an audience response system on the perceptions and educational performance of students. An audience response system called SIDRA (Immediate Audience Response System in Spanish) and two audience response systems with gamification features, R-G-SIDRA (gamified SIDRA with ranking) and RB-G-SIDRA (gamified SIDRA with ranking and badges), were used in a General and Descriptive Human Anatomy course. Students participated in an empirical study. In the academic year 2019–2020, a total of 90 students used RB-G-SIDRA, 90 students employed R-G-SIDRA in the academic year 2018–2019, and 92 students used SIDRA in the academic year 2017–2018. Statistically significant differences were found between final exam grades obtained by using RB-G-SIDRA and SIDRA, U = 39.211 adjusted p = 0.001 and RB-G-SIDRA and R-G-SIDRA U = 31.157 adjusted p = 0.015, thus finding strong evidence with respect to the benefit of the badges used in RB-G-SIDRA. Moreover, in the students’ SIDRA systems scores, statistically significant differences were found between RB-G-SIDRA and SIDRA, U = −90.521 adjusted p < 0.001, and between R-G-SIDRA and SIDRA, U = −87.998 adjusted p < 0.001. Significant correlations between individual and team scores were also found in all of the tests in RB-G-SIDRA and G-SIDRA. The students expressed satisfaction, engagement, and motivation with SIDRA, R-G-SIDRA, and RB-G-SIDRA, thus obtaining a final average assessment of 4.28, 4.61, and 4.47 out of 5, respectively. Students perform better academically with gamified versus non-gamified audience response systems. Findings can be used to build a gamified adaptive learning system.
Collapse
|
38
|
van Veenendaal H, Peters LJ, Ubbink DT, Stubenrouch FE, Stiggelbout AM, Brand PL, Vreugdenhil G, Hilders CG. Effectiveness of individual feedback and coaching on shared decision-making consultations in oncology care: Study protocol for a randomized clinical trial (Preprint). JMIR Res Protoc 2021; 11:e35543. [PMID: 35383572 PMCID: PMC9021945 DOI: 10.2196/35543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/18/2022] Open
Abstract
Background Shared decision-making (SDM) is particularly important in oncology as many treatments involve serious side effects, and treatment decisions involve a trade-off between benefits and risks. However, the implementation of SDM in oncology care is challenging, and clinicians state that it is difficult to apply SDM in their actual workplace. Training clinicians is known to be an effective means of improving SDM but is considered time consuming. Objective This study aims to address the effectiveness of an individual SDM training program using the concept of deliberate practice. Methods This multicenter, single-blinded randomized clinical trial will be performed at 12 Dutch hospitals. Clinicians involved in decisions with oncology patients will be invited to participate in the study and allocated to the control or intervention group. All clinicians will record 3 decision-making processes with 3 different oncology patients. Clinicians in the intervention group will receive the following SDM intervention: completing e-learning, reflecting on feedback reports, performing a self-assessment and defining 1 to 3 personal learning questions, and participating in face-to-face coaching. Clinicians in the control group will not receive the SDM intervention until the end of the study. The primary outcome will be the extent to which clinicians involve their patients in the decision-making process, as scored using the Observing Patient Involvement–5 instrument. As secondary outcomes, patients will rate their perceived involvement in decision-making, and the duration of the consultations will be registered. All participating clinicians and their patients will receive information about the study and complete an informed consent form beforehand. Results This trial was retrospectively registered on August 03, 2021. Approval for the study was obtained from the ethical review board (medical research ethics committee Delft and Leiden, the Netherlands [N20.170]). Recruitment and data collection procedures are ongoing and are expected to be completed by July 2022; we plan to complete data analyses by December 2022. As of February 2022, a total of 12 hospitals have been recruited to participate in the study, and 30 clinicians have started the SDM training program. Conclusions This theory-based and blended approach will increase our knowledge of effective and feasible training methods for clinicians in the field of SDM. The intervention will be tailored to the context of individual clinicians and will target the knowledge, attitude, and skills of clinicians. The patients will also be involved in the design and implementation of the study. Trial Registration Netherlands Trial Registry NL9647; https://www.trialregister.nl/trial/9647 International Registered Report Identifier (IRRID) DERR1-10.2196/35543
Collapse
Affiliation(s)
- Haske van Veenendaal
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Dutch Association of Oncology Patient Organizations, Utrecht, Netherlands
| | - Loes J Peters
- Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Dirk T Ubbink
- Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | | | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Paul Lp Brand
- Department of Innovation and Research, Isala Hospital, Zwolle, Netherlands
| | | | - Carina Gjm Hilders
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Board of Directors, Reinier de Graaf Hospital, Delft, Netherlands
| |
Collapse
|
39
|
Gamification and education: A pragmatic approach with two examples of implementation. J Clin Transl Sci 2021; 5:e181. [PMID: 34849256 PMCID: PMC8596077 DOI: 10.1017/cts.2021.806] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/13/2021] [Accepted: 06/15/2021] [Indexed: 11/07/2022] Open
Abstract
Leveraging elements of game design and theories of human motivation, gamification provides a variety of techniques to engage learners in novel ways. Our Clinical and Translational Science Award created the software platform (Kaizen-Education©) to deliver gamified educational content in 2012. Here, we explore two novel use cases of this platform to provide practical insights for leveraging these methods in educational settings: (1) national training in rigor, reproducibility, and transparency and (2) attainment of learner competency (n = 7) as a gauge of curricular effectiveness across Master of Public Health degree tracks (n = 5). Data were captured in real time during player interaction with Kaizen-Education© to provide descriptive analyses of player engagement in both implementation examples. We then assessed item analysis to assess knowledge gain and competency attainment. We have just begun to leverage the potential for gamification to engage learners, enhance knowledge acquisition, and document completion of training, across various learning environments. We encourage a systematic approach to gamification applying insights from self-determination theory to learners and learning environments, a methodical approach to game design and rigorous analysis after implementation to generate evidence-based insights to maximize educational return for time invested.
Collapse
|
40
|
Tenney-Soeiro R, Sieplinga K. Teaching about children with medical complexity: A blueprint for curriculum design. Curr Probl Pediatr Adolesc Health Care 2021; 51:101129. [PMID: 35086780 DOI: 10.1016/j.cppeds.2021.101129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Children with medical complexity make up a small portion of the pediatric population but utilize a large percentage of health care time and spending. The medical needs of children with medical complexity are highly variable and the education of healthcare providers in the care of these children has taken on more significance. Designing curricula and educational innovations related to the care of children with medical complexity can be challenging. Familiarity with the sociocultural theory, the zone of proximal development, Kolb's experiential learning model, and the educational resources that already exist allow for more ease in developing a curriculum that fits the needs of learners who may have a wide range of exposure to children with medical complexity. Flipped classroom models, simulations, asynchronous modules, and home and community experiences are all useful learning modalities to provide a varied and important curriculum. Taking advantage of the knowledge and skills of the many different members of the multi-disciplinary team caring for children with medical complexity is an important educational strategy that provides benefits to the learners and can enhance interprofessional education.
Collapse
Affiliation(s)
- Rebecca Tenney-Soeiro
- Associate Professor of Pediatrics, Perelman School of Medicine at University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Kira Sieplinga
- Assistant Professor Pediatrics, Program Director Pediatric Residency Spectrum Health, Helen DeVos Children's Hospital, Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| |
Collapse
|
41
|
Hansen SE, Defenbaugh N, Mathieu SS, Garufi LC, Dostal JA. A Mixed-Methods Exploration of the Developmental Trajectory of Autonomous Motivation in Graduate Medical Learners. MEDICAL SCIENCE EDUCATOR 2021; 31:2017-2031. [PMID: 34956711 PMCID: PMC8651867 DOI: 10.1007/s40670-021-01396-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Self-determination theory (SDT), when applied to curricular construction, emphasizes curiosity, self-awareness, and resilience. Physicians need these qualities to face the challenges of clinical practice. SDT offers a lens for medical educators to track learner development toward sustainable, rewarding careers. This study describes the changes observed in learner communications about feelings of competence, relatedness, and autonomy across a 3-year family medicine training program designed to develop activated, lifelong learners. METHODS This retrospective, mixed-methods case study uses a phenomenological approach to explore how 51 learners described their experiences at various intervals in residency training. Data collected from 2009 to 2015 from resident focus groups, competency assessment meetings, and faculty assessment reports inform a 3-stage analysis process to determine learner motivation levels along the SDT continuum. RESULTS Aggregated qualitative and quantitative data show residents' progression from introjection (controlled motivation) in PGY1, to identification (autonomous motivation) in PGY2, and integration (autonomous) by the end of PGY3. The examination of a single learner's data set reveals an advanced motivation level in PGY1 (identification), followed by a period of retrograde in PGY2 (introjection), then rebounding in PGY3 (identification), which illustrates how motivation level can be affected by external competency requirements and challenges related to career transitions. DISCUSSION The examination of self-motivation in medical learners has implications for curriculum development, assessment, teaching and self-directed learning, and resilience training. Learner awareness of intrinsic motivation, and the curriculum designed around it, can better prepare residents for challenges during residency and help them flourish in twenty-first-century medicine.
Collapse
Affiliation(s)
- Susan E. Hansen
- Lehigh Valley Health Network Family Medicine Residency Program, PO Box 1806, Allentown, PA 18101 USA
- University of South Florida Morsani College of Medicine, Tampa, FL USA
| | | | - Susan Snyder Mathieu
- Lehigh Valley Health Network Family Medicine Residency Program, PO Box 1806, Allentown, PA 18101 USA
- University of South Florida Morsani College of Medicine, Tampa, FL USA
| | | | - Julie A. Dostal
- University of South Florida Morsani College of Medicine, Tampa, FL USA
| |
Collapse
|
42
|
Chew QH, Tan E, Sum MY, Sim K. Inter-relationships between perception of educational environment and learning processes within medical undergraduate psychiatry teaching: a mediational analysis. MEDICAL EDUCATION ONLINE 2021; 26:1998944. [PMID: 34720060 PMCID: PMC8567940 DOI: 10.1080/10872981.2021.1998944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/19/2021] [Accepted: 10/23/2021] [Indexed: 06/13/2023]
Abstract
Amongst medical undergraduates, the perception of educational environment (EE) has been associated with academic achievement and positive attitude toward the course. Nonetheless, there are sparse data on how it influences various learning processes and outcomes especially within psychiatry training. Consistent with situativity and self-determination learning theories, we hypothesized that a positive perception of the EE within psychiatry postings will be beneficial for the learning process, specifically pertaining to greater motivation to learn, better engagement, allowing them to feel more equipped, and greater appreciation of the subject. The DREEM (Dundee Ready Education Environment Measure) was administered to fourth-year medical undergraduate students from the Yong Loo Lin School of Medicine, Singapore, undergoing psychiatry rotations from 2015 to 2019. The students also completed five additional items evaluating the specific learning processes (motivation to learn, engagement, equipping, and appreciation of the subject) and overall rating of the posting. We examined the relationship between DREEM domains and learning processes using correlation analysis. We explored learning processes as mediators of the relationship between total DREEM scores and overall rating of the posting. Altogether, 1343 (response rate 89.5%) medical undergraduates participated in the study. The overall DREEM score was 157.01 ± 15.86. Overall DREEM and subdomain scores were significantly correlated with several learning processes (r = 0.354 to 0.558, all p < .001). Motivation and engagement were significant mediators of the relationship between total DREEM scores and overall rating of the psychiatry posting. Our results highlighted that a positive perception of EE was associated with the specific learning processes that mediated the overall rating of the posting. In the context of relevant learning theories and our study findings, improvement of the EE within undergraduate psychiatry training can potentially enhance overall learning experience through better motivation and engagement of our learners.
Collapse
Affiliation(s)
- Qian Hui Chew
- Research Division, Institute of Mental Health, Singapore
| | - Eelin Tan
- Radiology, Kk Women’s and Children’s Hospital, Singapore
| | - Min Yi Sum
- Research Division, Institute of Mental Health, Singapore
| | - Kang Sim
- West Region, Institute of Mental Health, Singapore
| |
Collapse
|
43
|
Goldman J, Smeraglio A, Lo L, Kuper A, Wong BM. Theory in quality improvement and patient safety education: A scoping review. PERSPECTIVES ON MEDICAL EDUCATION 2021; 10:319-326. [PMID: 34609733 PMCID: PMC8633332 DOI: 10.1007/s40037-021-00686-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Theory plays an important role in education programming and research. However, its use in quality improvement and patient safety education has yet to be fully characterized. The authors undertook a scoping review to examine the use of theory in quality improvement and patient safety education. METHODS Eligible articles used theory to inform the design or study of a quality improvement or patient safety curriculum. The authors followed scoping review methodology and searched articles referenced in 20 systematic reviews of quality improvement and patient safety education, or articles citing one of these reviews, and hand searched eligible article references. Data analysis involved descriptive and interpretive summaries of theories used and the perspectives the theories offered. RESULTS Eligibility criteria were met by 28 articles, and 102 articles made superficial mention of theory. Eligible articles varied in professional group, learning stage and journal type. Theories fell into two broad categories: learning theories (n = 20) and social science theories (n = 11). Theory was used in the design (n = 12) or study (n = 17) of quality improvement and patient safety education. The range of theories shows the opportunity afforded by using more than one type of theory. DISCUSSION Theory can guide decisions regarding quality improvement and patient safety education practices or play a role in selecting a methodology or lens through which to study educational processes and outcomes. Educators and researchers should make deliberate choices around the use of theory that relates to aspects of an educational program that they seek to illuminate.
Collapse
Affiliation(s)
- Joanne Goldman
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
- The Wilson Centre, Toronto, Ontario, Canada.
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Andrea Smeraglio
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
- Division of Hospital & Specialty Medicine, Portland Veterans Administration Medical Center, Portland, OR, USA
| | - Lisha Lo
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ayelet Kuper
- The Wilson Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian M Wong
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
44
|
Abstract
The vast majority of clinical skills teaching at our medical school in London is delivered through a peer teaching programme, with research demonstrating that medical students unequivocally prefer being taught clinical skills by peer teachers (students) over-qualified physicians. Peer teaching holds a plethora of benefits for both the learner and the teacher; encouraging academic and professional growth for teachers while instilling confidence in tutees through an improved learning atmosphere. Teaching is an essential skill for all physicians, and peer teaching is an invaluable method to cultivate these teaching skills throughout medical education. This article outlines 12 tips on how medical students can be effective and successful clinical skills peer teachers when faced with medical teaching opportunities, whether physically or remotely conducted. We reflect upon our roles as Peer Teacher Leads, overseeing a team of 200 medical student clinical skills peer teachers on behalf of the faculty at our university in London. We are responsible for leadership and quality assurance, holding key input into the organisation, development and delivery of clinical skills teaching. Therefore, we are able to impart unique insight and experience. This practical guidance is gathered from feedback, experience and the wider literature on the topic of peer teaching in clinical skills. We hope that these tips will enable medical student teachers to become more confident and competent in providing worthwhile training to their peers.
Collapse
|
45
|
Viljoen CA, Millar RS, Manning K, Hoevelmann J, Burch VC. Clinically contextualised ECG interpretation: the impact of prior clinical exposure and case vignettes on ECG diagnostic accuracy. BMC MEDICAL EDUCATION 2021; 21:417. [PMID: 34344375 PMCID: PMC8336410 DOI: 10.1186/s12909-021-02854-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/26/2021] [Indexed: 05/29/2023]
Abstract
BACKGROUND ECGs are often taught without clinical context. However, in the clinical setting, ECGs are rarely interpreted without knowing the clinical presentation. We aimed to determine whether ECG diagnostic accuracy was influenced by knowledge of the clinical context and/or prior clinical exposure to the ECG diagnosis. METHODS Fourth- (junior) and sixth-year (senior) medical students, as well as medical residents were invited to complete two multiple-choice question (MCQ) tests and a survey. Test 1 comprised 25 ECGs without case vignettes. Test 2, completed immediately thereafter, comprised the same 25 ECGs and MCQs, but with case vignettes for each ECG. Subsequently, participants indicated in the survey when last, during prior clinical clerkships, they have seen each of the 25 conditions tested. Eligible participants completed both tests and survey. We estimated that a minimum sample size of 165 participants would provide 80% power to detect a mean difference of 7% in test scores, considering a type 1 error of 5%. RESULTS This study comprised 176 participants (67 [38.1%] junior students, 55 [31.3%] senior students, 54 [30.7%] residents). Prior ECG exposure depended on their level of training, i.e., junior students were exposed to 52% of the conditions tested, senior students 63.4% and residents 96.9%. Overall, there was a marginal improvement in ECG diagnostic accuracy when the clinical context was known (Cohen's d = 0.35, p < 0.001). Gains in diagnostic accuracy were more pronounced amongst residents (Cohen's d = 0.59, p < 0.001), than senior (Cohen's d = 0.38, p < 0.001) or junior students (Cohen's d = 0.29, p < 0.001). All participants were more likely to make a correct ECG diagnosis if they reported having seen the condition during prior clinical training, whether they were provided with a case vignette (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.24-1.71) or not (OR 1.58, 95% CI 1.35-1.84). CONCLUSION ECG interpretation using clinical vignettes devoid of real patient experiences does not appear to have as great an impact on ECG diagnostic accuracy as prior clinical exposure. However, exposure to ECGs during clinical training is largely opportunistic and haphazard. ECG training should therefore not rely on experiential learning alone, but instead be supplemented by other formal methods of instruction.
Collapse
Affiliation(s)
- Charle André Viljoen
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Cape Heart Institute, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
| | - Rob Scott Millar
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Kathryn Manning
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Julian Hoevelmann
- Cape Heart Institute, University of Cape Town, Observatory, Cape Town, 7925, South Africa
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Hospital, Homburg/Saar, Germany
| | - Vanessa Celeste Burch
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| |
Collapse
|
46
|
Sheng, AY, Gottlieb, M, Welsh, L. Leveraging learner-centered educational frameworks to combat health mis/disinformation. AEM EDUCATION AND TRAINING 2021; 5:e10711. [PMID: 34926972 PMCID: PMC8643155 DOI: 10.1002/aet2.10711] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 06/02/2023]
Affiliation(s)
- Alexander Y. Sheng,
- Department of Emergency MedicineBoston Medical CenterBostonMassachusettsUSA
- Boston University School of MedicineBostonMassachusettsUSA
| | - Michael Gottlieb,
- Director of Emergency Ultrasound DivisionDepartment of Emergency MedicineRush University Medical CenterChicagoIllinoisUSA
| | - Laura Welsh,
- Department of Emergency MedicineBoston Medical CenterBostonMassachusettsUSA
- Boston University School of MedicineBostonMassachusettsUSA
| |
Collapse
|
47
|
Bradley EB, Waselewski EA, Gusic ME. How Do Clerkship Students Use EPA Data? Illuminating Students' Perspectives as Partners in Programs of Assessment. MEDICAL SCIENCE EDUCATOR 2021; 31:1419-1428. [PMID: 34457983 PMCID: PMC8368261 DOI: 10.1007/s40670-021-01327-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The implementation of programs of assessment based on Entrustable Professional Activities (EPAs) offers an opportunity for students to obtain unique data to guide their ongoing learning and development. Although authors have explored factors that contribute to trust-based decisions, learners' use of assessors' decisions about the level of supervision they need has not been fully investigated. METHODS In this study, we conducted semi-structured interviews of clerkship students who participated in the first year of our EPA program to determine how they interpret and use supervision ratings provided in EPA assessments. Content analysis was performed using concept-driven and open coding. RESULTS Nine interviews were completed. Twenty-two codes derived from previous work describing factors involved in trust decisions and 12 novel codes were applied to the interview text. Analyses revealed that students focus on written and verbal feedback from assessors more so than on supervision ratings. Axial coding revealed a temporal organization that categorized how students considered the data from EPA assessments. While factors before, during, and after an assessment affected students' use of information, the relationship between the student and the assessor had impact throughout. CONCLUSIONS Although students reported varying use of the supervision ratings, their perspectives about how assessors and students interact and/or partner before, during, and after assessments provide insights into the importance of an educational alliance in making a program of assessment meaningful and acceptable to learners.
Collapse
Affiliation(s)
- Elizabeth B. Bradley
- Center for Medical Education Research and Scholarly Innovation, Office of Medical Education, University of Virginia School of Medicine, VA Charlottesville, USA
| | - Eric A. Waselewski
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan USA
| | - Maryellen E. Gusic
- Center for Medical Education Research and Scholarly Innovation, Office of Medical Education, University of Virginia School of Medicine, VA Charlottesville, USA
| |
Collapse
|
48
|
Sewell JL. Going with the cognitive (load theory) flow. MEDICAL EDUCATION 2021; 55:770-772. [PMID: 33786868 DOI: 10.1111/medu.14533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Justin L Sewell
- Department of Medicine, Division of Gastroenterology, San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
49
|
Sachdeva AK. Preceptoring, proctoring, mentoring, and coaching in surgery. J Surg Oncol 2021; 124:711-721. [PMID: 34212384 DOI: 10.1002/jso.26585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/09/2022]
Abstract
Contemporary models of surgical education that are founded on sound educational theories and constructs need to be used across the continuum of professional development of surgeons starting with the first day of medical school, through surgery residency and fellowship training, to the last day of surgical practice. The highly learner-centered and individually-focused special interventions of preceptoring, proctoring, mentoring, and coaching should be linked to innovative competency-based education models to address the educational needs of learners at all levels, and especially of surgeons in practice to continually improve their knowledge, skills, and performance, with the aspirational goal of achieving expertise and mastery. Each of these interventions is distinct with its own unique characteristics, applications, and anticipated impact, which must be clearly recognized for the interventions to be used most effectively. Broad acceptance and adoption of the aforementioned special interventions require recognition of the value each brings to the learner and the educational program. Professional organizations should play a key role in designing innovative educational programs that include these interventions, supporting their integration into surgical education and surgical practice, and influencing changes in the cultures in surgery to facilitate broad adoption of these interventions.
Collapse
Affiliation(s)
- Ajit K Sachdeva
- Division of Education, American College of Surgeons, Chicago, Illinois, USA
| |
Collapse
|
50
|
Seligman L, Abdullahi A, Teherani A, Hauer KE. From Grading to Assessment for Learning: A Qualitative Study of Student Perceptions Surrounding Elimination of Core Clerkship Grades and Enhanced Formative Feedback. TEACHING AND LEARNING IN MEDICINE 2021; 33:314-325. [PMID: 33228392 DOI: 10.1080/10401334.2020.1847654] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Problem: Medical students perceive honors grading during core clerkships as unfair and inequitable, and negatively impacting their learning and wellbeing. Eliminating honors grading, a powerful extrinsic motivator, and emphasizing formative feedback may address these problems and promote intrinsic motivation and learning. However, it is unknown how transitioning from honors to pass/fail grading with enhanced formative feedback in the core clerkship year may affect student learning experiences, wellbeing, and perceptions of the learning environment. Intervention: Core clerkship grading was transitioned from honors/pass/fail to pass/fail at one US medical school. In addition, the requirement for students to obtain formative supervisor feedback was formalized to twice per week. Context: This qualitative study utilized semi-structured interviews to explore the perceptions among core clerkship students of learning and assessment. Interview questions addressed motivation, wellbeing, learning behaviors, team dynamics, feedback, and student and supervisor attitudes regarding assessment changes. The authors analyzed data inductively using thematic analysis informed by sensitizing concepts related to theories of motivation (goal orientation theory and self-determination theory). Impact: Eighteen students participated, including five with experience in both honors-eligible and pass/fail clerkships. The authors identified three major themes in students' descriptions of the change in approach to assessment: student engagement in clerkships, wellbeing, and recognition of learning context. Student engagement subthemes included intrinsic motivation for patient care rather than performing; sense of agency over learning, including ability to set learning priorities, seek and receive feedback, take learning risks, and disagree with supervisors, and collaborative relationships with peers and team members. Positive wellbeing was characterized by low stress, sense of authenticity with team members, prioritized physical health, and attention to personal life. Learning context subthemes included recognition of variability of clerkship contexts with pass/fail grading mitigating fairness and equity concerns, support of the grading change from residents and some attendings, and implications surrounding future stress and residency selection. Lessons Learned: Students perceive a transition from honors grading to pass/fail with increased feedback as supporting their engagement in learning, intrinsic motivation, and wellbeing. Drivers of wellbeing appear to include students' feelings of control, achieved through the ability to seek learning opportunities, teaching, and constructive feedback without the perceived need to focus on impressing others. Ongoing evaluation of the consequences of this shift in assessment is needed.
Collapse
Affiliation(s)
- Lee Seligman
- Internal Medicine, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Abdikarin Abdullahi
- University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Arianne Teherani
- University of California, San Francisco School of Medicine, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, California, USA
| | - Karen E Hauer
- University of California, San Francisco School of Medicine, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, California, USA
| |
Collapse
|