Students' goal orientations, perceptions of early clinical experiences and learning outcomes

Learning strategies for the advanced trainee in specialist training

BACKGROUND

A significant factor of clinicians' learning is based on their ability to effectively transfer acquired knowledge, skills, and attitudes from specialty-specific clinical courses to their working environment.

MATERIAL AND METHOD

We conducted semi-structured interviews with 20 anaesthesiologist trainees (i.e. residents) in four group and five individual interviews using SRL principles as sensitizing concepts. Data were collected and analyzed iteratively using thematic analysis.

RESULTS

Advanced trainees are highly motivated to explore what they have learned in specialty-specific courses, but they often face several barriers in implementing their learning in the workplace environment. Four themes emerged from the interview data: 'Be ready to learn', "Take the 'take-home-messages' home', "Be ready to create your own opportunities', and "Face it, it's not entirely up to you'. Understanding the challenges regarding transferring knowledge from courses to the working environment is an important lesson for assisting trainees set their learning goals, monitor their progress, and re-evaluate their SRL processes.

CONCLUSION

Even for advanced trainees, successfully transferring knowledge from specialty-specific courses often requires adequate commitment and support. Medical supervisors and other relevant stakeholders must be aware of their shared responsibility for creating individual environments that support opportunities for trainees to self-regulate their learning.

Medical students' general and radiology-specific motivation: Correlations, stability and associations with learning strategies and ability beliefs

PURPOSE

This study investigated general and subject-specific motivational beliefs from the perspectives of self-determination theory (i.e. intrinsic, identified, introjected, and extrinsic motivation) and achievement goal theory (i.e. mastery, performance-approach, and -avoidance goal orientation including the respective classroom goal structures), their interrelations, their stability over time, and their associations with desirable outcomes (i.e. deep-level learning strategies, self-concept of ability). It was hypothesized that motivational beliefs are interrelated but demonstrate a distinct correlational pattern depending on whether they were assessed as general or subject-specific motivation. In addition, motivational beliefs were hypothesized to relate to learning strategies and ability beliefs.

METHODS

Medical students (n = 146) participated in this longitudinal study with measurement points at the beginning and end of a semester. The questionnaire included established motivational scales to assess motivational beliefs and desirable outcomes. Measurement models were tested using confirmatory factor analyses; correlations of scale means were investigated to assess the nomological network of motivational beliefs.

RESULTS

As expected, intrinsic and identified motivation were associated with mastery goal orientation and with desirable outcome variables, such as the use of deep-level learning strategies. General and subject-specific motivation exhibited distinct correlational patterns. Motivation was relatively stable over time. Results did not confirm the factor structure of classroom goal structure.

CONCLUSIONS

The study emphasizes the benefit of a subject-specific conceptualization of motivation and the need for a careful adaptation of theoretical constructs from the secondary school context to make them fruitful for the promotion of medical students' motivation. Medical teachers can use established motivational interventions (e.g. using an individual frame of reference for feedback) to support students' adaptive motivational beliefs (e.g. self-determined motivation, mastery goals). Given the subject specificity of motivation, it seems beneficial to promote adaptive motivation in the respective medical specialty regardless of students' general motivational characteristics.

Good bedside teaching on secondary care placement: The student perspective

BACKGROUND

Students' experience of bedside teaching (BST) on clinical placement has significantly decreased, with a shift in teaching away from the bedside. The educational value of teaching on ward rounds (WRs) has also been debated.

OBJECTIVE

This research considered what constitutes good BST from the student perspective; guidance to support clinician teachers was produced.

METHODS

Semi-structured interviews were conducted with 10 second-year students and 10 fourth- and fifth-year students studying at Leeds Medical School. Data were analysed using thematic analysis.

FINDINGS

We identified four themes: (1) benefits of early clinical experience, (2) qualities of good clinical teachers, (3) shift in preference from structured to opportunistic learning and (4) increased valuing of the WR as a site of learning.

CONCLUSION

The structure of BST should be adapted to the learners' stage of training with a graduated approach, from a structured preparation for observation to authentic, observed participation with feedback. Students' early lack of clinical knowledge makes it difficult to meaningfully observe and partake in ward activities. During early clinical experience, good teaching is perceived as structured and supported by the clinician. As learners progress, they are better able to engage in opportunistic learning, which actively involves them in patient care. They also valued structured teaching and feedback. While patient contact should be supervised, a more participatory, observed and feedback-driven approach should be adopted in the later years. Teaching must address both knowledge and skills required to be a doctor; this is facilitated by an active role in patient care.

Academic Leadership Academy Summer Program: Clerkship Transition Preparation for Underrepresented in Medicine Medical Students

PROBLEM

Enhancing workforce diversity by increasing the recruitment of students who have been historically excluded/underrepresented in medicine (UIM) is critical to addressing healthcare inequities. However, these efforts are inadequate when undertaken without also supporting students' success. The transition to clerkships is an important and often difficult to navigate inflection point in medical training where attention to the specific needs of UIM students is critical.

INTERVENTION

We describe the design, delivery, and three-year evaluation outcomes of a strengths-based program for UIM second year medical students. The program emphasizes three content areas: clinical presentations/clinical reasoning, community building, and surfacing the hidden curriculum. Students are taught and mentored by faculty, residents, and senior students from UIM backgrounds, creating a supportive space for learning.

CONTEXT

The program is offered to all UIM medical students; the centerpiece of the program is an intensive four-day curriculum just before the start of students' second year. Program evaluation with participant focus groups utilized an anti-deficit approach by looking to students as experts in their own learning. During focus groups mid-way through clerkships, students reflected on the program and identified which elements were most helpful to their clerkship transition as well as areas for programmatic improvement.

IMPACT

Students valued key clinical skills learning prior to clerkships, anticipatory guidance on the professional landscape, solidarity and learning with other UIM students and faculty, and the creation of a community of peers. Students noted increased confidence, self-efficacy and comfort when starting clerkships.

LESSONS LEARNED

There is power in learning in a community connected by shared identities and grounded in the strengths of UIM learners, particularly when discussing aspects of the hidden curriculum in clerkships and sharing specific challenges and strategies for success relevant to UIM learners. We learned that while students found unique benefits to preparing for clerkships in a community of UIM students, near peers, and faculty, future programs could be enhanced by pairing this formal intensive curriculum with more longitudinal opportunities for community building, mentoring, and career guidance.

A mixed methods exploration of the emergence of goal orientation in medical students' individualized learning plans

PURPOSE

Goal orientation (GO) describes an individual's approach to different achievement situations. Understanding the motivations and approach to achieving goals of medical students is vital with the increasing emphasis on self-directed learning. The purpose of this study was to identify themes in self-improvement reflections that relate to each GO dimension (learning, performance-prove, and performance-avoid).

METHODS

A sequential explanatory mixed methods design was used. GO data was used to categorize students into groups aligning with the GO dimension identified in the previous stage of quantitative analysis. Individualized learning plans (ILPs) for each GO dimension group were coded inductively to identify emergent themes related to goal setting and achievement.

RESULTS

The learning GO group was the largest of the three GOs. Five themes were identified from inductive analysis: importance of practice, identifying elements that helped, identifying structural barriers, opportunities for improvement, and acknowledging experience. While these themes occur across GO, patterns exist within their ILPs based on GO.

CONCLUSIONS

We identified common themes for motivations of medical students, and these motivations might differ depending on their GO. Further exploration into the themes over the course of their training will provide additional insights on what factors may be involved in student motivations towards learning and achievement. Educators can use this information to individualize feedback and students can better understand their motivations towards achieving goals.

Emergency Medical Technician Training in Medical School on Preparation for Required National Board Exams and Clerkship Rotations: Results from a Student Survey

PURPOSE

The University of South Carolina School of Medicine Greenville has incorporated Emergency Medical Technician (EMT) training into the first semester curriculum with students becoming state-certified EMTs and completing one ambulance shift per month throughout their pre-clerkship years. Although there have been programs that have reported EMT experiences in the pre-clinical years of medical education, student perceptions of how the EMT experiences help prepare them for board exams and clerkships is limited. Therefore, the aim of this study was to measure student perceptions regarding the impact of an EMT course and training in the pre-clerkship curriculum in medical school on helping prepare them for national board exams (ie USMLE^® Step 1, 2 Clinical Knowledge (CK), 2 Clinical Skills (CS)) and clerkship rotations.

METHODS

Second-, third-, and fourth-year medical students at the University of South Carolina School of Medicine Greenville completed an anonymous voluntary survey with response rates of 66.3%, 55.2%, and 56.9%, respectively. The study was reviewed and exempted by the University of South Carolina Institutional Review Board.

RESULTS

Seventeen percent, 14%, and 41% of students agreed/strongly agreed an EMT course helped prepare them for the USMLE Step 1, Step 2 CK, and Step 2 CS exam, respectively. Sixty-four percent of students agreed/strongly agreed that an EMT course and experience helped prepare them for clerkship rotations.

CONCLUSION

The findings in this study support EMT training and experience as an EMT as one method to help prepare students for clerkship rotations.

The chicken and the egg: Clinical reasoning and uncertainty tolerance

Richmond aruges that clinical reasoning and uncertainty tolerance development occur simultaneously and that deficit in either domain will affect the development of the other. Implications for curriculum design are offered.

Impacts of early clinical exposure on undergraduate student professionalism-a qualitative study

INTRODUCTION

Early clinical exposure (ECE), or authentic human contact in a social or clinical context during preclinical training, has been adopted by many medical schools. This study aims to investigate how medical students' sense of professionalism changed after ECE intervention, with the aim of informing curriculum design to enhance student awareness of the importance of medical professionalism.

METHOD

Focus groups of ECE students were held to collect data for the study. All participants read interview guidelines before starting. During the focus groups, the students discussed their medical obligations as perceived throughout the course, which offered a choice between four different ECE tracks. They were then asked to report their understanding of the situations they encountered during the course and reflect on their implications.

RESULTS

Six focus groups of 22 students in total from a medical school in northern Taiwan were held shortly after the students completed an ECE course in September 2019. From their responses, 10 categories relating to medical professionalism were deduced categorized under 5 major dimensions. An additional 8 sub-dimensions on attitudes and 2 sub-dimensions on personal well-being were also identified as new categories separate from but related to medical professionalism. After the ECE intervention, about 59% of participants redefined their understanding of medical professionalism.

CONCLUSION

ECE and intensive interaction with key stakeholders, including patients and their families, help students in the early stages of medical education form and cultivate a sense of medical professionalism. However, the relationship between participants' personalities, motivations, and clinical activities requires further investigation.

Perceptions of Lecturers, Administrators, and Students About the Workplace as Learning Environment for Undergraduate Medical Students at a National Referral and Teaching Hospital in Uganda

PURPOSE

The workplace is an important element of the learning ecosystem for medical students during their competence development. It offers engagement opportunities that enable students to participate in clinical activities as part of learning in their preparation for future clinical practice. The purpose of this study was to explore the perceptions and experiences of lecturers, administrators, and students of Makerere University College of Health Sciences about the workplace, at Mulago National Referral and Teaching Hospital, as a learning environment for the undergraduate medical students with the ultimate aim of identifying opportunities and challenges to learner competence development in the learning environment for purposes of improvement.

METHODS

The study design was cross-sectional descriptive with a qualitative approach using key informant interviews for the lecturers and administrators and focus group discussions for the students. The framework method was used to perform thematic data analysis.

RESULTS

The workplace was perceived to be well endowed with adequate patient numbers, a suitable case mix and unrestricted access to patients which enhanced competence development. The challenges reported included inadequate resources, such as infrastructure, equipment and supplies and overcrowding, which compromised competence development. The resource challenge appeared insurmountable in the context of two autonomous institutions with divergent planning priorities in terms of teaching, research, and patient care.

CONCLUSION

There were mixed perceptions about the learning environment at the hospital with both enabling and challenging factors on the backdrop of two autonomous institutions with divergent planning priorities in terms of teaching, research, and patient care. In order to improve the workplace as a learning environment, it is imperative that the two institutions find common ground in terms of clinical care, students' teaching and provision of supplies that are essential not only for patient care but competence development of the learners who are the clinicians of tomorrow.

Effective competency-based medical education requires learning environments that promote a mastery goal orientation: A narrative review

PURPOSE

Competency-based medical education (CBME) emphasizes the need for learners to be central to their own learning and to take an active role in learning. This approach has a dual aim: to encourage learners to actively engage in their own learning, and to push learners to develop learning strategies that will prepare them for lifelong learning. This review paper proposes a theoretical bridge between CBME and lifelong learning and puts forth the argument that in order for CBME programs to produce the physicians truly needed in our society now and in the future, learning environments must be intentionally designed to foster mastery goal orientations and to support the development of adaptive self-regulated learning skills and behaviours.

MATERIALS AND METHODS

This narrative literature review incorporated results of searches conducted by a subject librarian in PsycInfo and MedLine. Articles were also identified through reference lists of identified papers to capture older key citations. Analysis of the literature used a constructivist epistemological approach to develop an integrative description of the interaction of achievement goal orientation, self-regulated learning, learning environment, and lifelong learning.

RESULTS

Findings from achievement goal theory research support the assumption that adoption of a mastery goal orientation facilitates the use of adaptive learning behaviours, such as those described in self-regulated learning theory. Adaptive self-regulated learning strategies, in turn, facilitate effective lifelong learning. The authors offer evidence for how learning environments influence goal orientations and self-regulated learning, and propose that CBME programs intentionally plan for such learning environments. Finally, the authors offer specific suggestions and examples for how learning environments can be designed or adjusted to support adoption of a mastery goal orientation and use of self-regulated learning behaviours and strategies to help support development of adaptive lifelong learners.

From Passive Gatekeeper to Quarterback: Evolving Perceptions of Primary Care Among Medical Students in Longitudinal Outpatient Clerkships

BACKGROUND

Longitudinal clerkships provide students with meaningful clinical care roles that promote learning and professional development. It remains unclear how longitudinal primary care clerkships inform students' perceptions of primary care.

OBJECTIVE

To explore perceptions of primary care among medical students enrolled in longitudinal primary care clerkships.

DESIGN

Qualitative, semi-structured interviews with medical students over 4 years.

PARTICIPANTS

Thirty-eight medical students participated at baseline; 35 participated in a 2-year follow-up interview; 24 participated at 4 years. Each student was enrolled in one of two longitudinal primary care clerkships: a team-based Education-Centered Medical Home (ECMH) or a one-on-one individual preceptorship (IP).

APPROACH

De-identified interview transcripts were analyzed using a process of open and axial coding, followed by elaborative coding for longitudinal analysis. Codes were compiled into a set of themes and compared across time periods and between clerkships.

KEY RESULTS

Students reported that primary care serves as a first point of contact, emphasizing longitudinal care with a wide scope of practice and approaching patient care with a biopsychosocial perspective. Student perceptions of primary care greatly expanded over the course of 4 years: for instance, initial perceptions of primary care physicians evolved from "passive gatekeeper" to a more nuanced "quarterback." Students in ECMH, whose clerkship provided more opportunity for patient continuity, further reflected on the relationships they themselves developed with patients.

CONCLUSIONS

Regardless of their eventual specialty choice, longitudinal experiences may aid all students in fostering a sense of the broad scope and importance of primary care. However, without numerous opportunities to witness continuity of care, students may perceive primary care as having limited scope and importance. Longitudinal clerkships, emphasizing continuity with patients and preceptors, may foster in students a broad and nuanced perspective of the scope of primary care as a field.

Going against the grain: An exploration of agency in medical learning

BACKGROUND

Learner-centred medical education relies on learner agency. While attractive in principle, the actual exercise of agency is a complicated process, potentially constrained by social norms and cultural expectations. In this study, we explored what it means to be an agentic learner in medicine, and how individuals experience and harness agency in their learning.

METHODS

Using a constructivist grounded theory approach, we interviewed 19 physicians or physicians-in-training who identified as 'learning mavericks'; this strategy facilitated recruiting participants with a strong sense of themselves as agentic learners. We asked them about atypical learning choices they had made, about support and resistance they encountered and about how they managed to carve a distinct path for themselves. Data collection and analysis were concurrent and iterative, grounded in the constant comparative approach.

RESULTS

We identified one overarching concept: agency is work. The work of exercising agency was compounded by a system of professional training that was perceived to promote conformity and to resist individual learner agency. Individuals' capacity to exercise agency appeared to be bolstered by social capital, self-knowledge and mentorship.

DISCUSSION AND CONCLUSIONS

Our work extends and elaborates the understanding of learner agency in medicine, highlighting the exercise of agency as a sometimes counter-cultural act that requires learners to resist considerable pressure to conform to social and professional expectations. Agency may come more easily to strong learners who have established their ability to succeed within the system's expectations. Enhancing learner agency thus requires careful attention to learner support. Mentorship that both helps learners to identify appropriate learning paths and shields them from the pull of social expectations may be especially fruitful.

From Grading to Assessment for Learning: A Qualitative Study of Student Perceptions Surrounding Elimination of Core Clerkship Grades and Enhanced Formative Feedback

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.

Vertical integration in medical education: the broader perspective

Curricular integration represents collaborations between disciplines to establish a coherent curriculum and has become the dominant recommendation for medical education in the second half of the twentieth century. Vertical integration specifically is the integration between the clinical and basic science parts throughout the program. Vertically integrated curricula present basic sciences imbedded in a clinical context from the start of medical school.The authors briefly discuss vertical integration in relationship with context theory, motivation theory, professional identity formation, transition to practice and the continuum of education and practice. They conclude that vertical integration, rather than horizontal integration, extends far beyond curriculum structure. They consider vertical integration a philosophy of education, with impact on students' maturation and engagement with the profession, and which applies not only to undergraduate education but to the lifelong learning of professionals. The definition of vertical integration as "an educational approach that fosters a gradual increase of learner participation in the professional community through a stepwise increase of knowledge-based engagement in practice with graduated responsibilities in patient care" is more comprehensive than its older conceptualization.

The role and related variables of workplace learning in quantitative research

Purpose

The purpose of this study is to review the definition, perspective, measurement and context of workplace learning and explored workplace learning to identify its role in quantitative research.

Design/methodology/approach

Through an integrative review of the literature, the following four roles that workplace learning has played in these studies were identified: workplace learning as an antecedent, a mediator, a moderator and an outcome.

Findings

This paper synthesized results for workplace learning in 45 studies. A total of 88 variables related to workplace learning were identified after four overlapped variables (autonomy, social support, work engagement and workload) in multiples areas were excluded from a total of 92 variables (56 antecedents, 8 mediators, 7 moderators and 21 outcomes).

Research limitations/implications

Because this study identified four roles of workplace learning (as antecedent, mediator, moderator and outcome), this study did not focus on the process of learning in the workplace. Additional study is needed to investigate how workplace learning can lead to outcomes and how this process can link workplace learning and its consequences.

Originality/value

This paper synthesized the antecedents, mediators, moderators and outcomes for workplace learning by integrating the findings in this study. This provided a comprehensive framework that could be used by researchers to continue the empirical research on this topic to develop the dynamics between individual, group, job and organizational variables on the one hand and workplace learning on the other.

Relationship between metacognitive awareness and motivation to learn in medical students

BACKGROUND

In self-regulated learning, learning is defined as metacognitively guided, intrinsically motivated and strategic. In the context of medical education, the development of self-regulated learning can be associated with better academic and clinical performance. Hence, this report focuses on demonstrating the association between metacognitive awareness and motivation to learn among medical students in the clinical sciences portion of their education (3rd and 4th years of the medical programme) and characterizing medical students' motivational factors.

METHODS

We performed a cross-sectional study with a qualitative and quantitative approach involving medical students from the University of Sao Paulo (USP) in Brazil. We have selected validated self-report questionnaires for the evaluation of metacognition (the Schraw and Dennison Metacognitive Awareness Inventory - MAI) and motivation to learn (the Baranik, Barron and Finney Achievement Goals for a Work Domain - AGWD). MAI has two domains: knowledge about cognition and regulation of cognition. AGWD divides achievement goals into mastery approach, mastery avoidance, performance approach and performance avoidance goal orientations. We also performed a qualitative analysis based on an open-ended question: "What motivates me the most in medical training?"

RESULTS

One hundred eighty-five students completed the questionnaires: 103 (55.67%) were men, 110 (59.45%) were in their fourth year of the medical programme, and 152 (82.16%) were up to 24 years old. Only the knowledge about cognition domain of MAI was significantly associated with motivation to learn. We found that higher scores on the knowledge about cognition domain of MAI was associated with the mastery approach goal orientation (p = 0.003, median 0.71, IQR 0.23) and that lower scores on this same domain was associated with a mastery avoidance goal orientation (p = 0.034, median 0.65, IQR 0.14). The open-ended question showed that altruism, personal satisfaction, financial feedback, personal and supportive networks and graduating were motivational factors.

CONCLUSIONS

Metacognitive awareness and motivation to learn are closely related. This association may represent a potential target for the educational process, as deans and faculty can adopt strategies focused on promoting self-regulated learning concerning students' motivational factors. This could enhance academic outcomes and promote more enjoyable learning.

Social Identification with the Medical Profession in the Transition from Student to Practitioner

Phenomenon: This study explores professional identity formation during a final year of medical school designed to ease the transition from student to practitioner. Although still part of the undergraduate curriculum, this "transitional year" gives trainees more clinical responsibilities than in earlier rotations. Trainees are no longer regarded as regular clerks but work in a unique position as "semi-physicians," performing similar tasks as a junior resident during extended rotations. Approach: We analyzed transcripts from interviews with 21 transitional-year medical trainees at University Medical Center Utrecht about workplace experiences that affect the development of professional identity. We used Social Identity Approach as a lens for analysis. This is a theoretical approach from social psychology that explores how group memberships constitute an important component of individual self-concepts in a process called 'social identification.' The transcripts were analyzed using thematic analysis, with a focus on how three dimensions of social identification with the professional group emerge in the context of a transitional year: cognitive centrality (the prominence of the group for self-definition), in-group affect (positivity of feelings associated with group membership) and in-group ties (perception of fit and ties with group members). Findings: Students were very aware of being a practitioner versus a student in the position of semi-physician and performing tasks successfully (i.e., cognitive centrality). Students experienced more continuity in patient care in transitional-year rotations than in previous clerkships and felt increased clinical responsibility. As a semi-physician they felt they could make a significant contribution to patient care. Students experienced a sense of pride and purpose when being more central to their patients' care (i.e., in-group affect). Finally, in extended rotations, the trainees became integrated into daily social routines with colleagues, and they had close contact with their supervisors who could confirm their fit with the group, giving them a sense of belonging (i.e., in-group ties). Insights: Using the three-dimension model of social identification revealed how students come to identify with the social group of practitioners in the context of a transitional year with extended rotations, increased clinical responsibilities, and being in the position of a "semi-physician." These findings shed light on the identity transition from student to practitioner within such a curricular structure.

Sport Practitioners as Sport Ecology Designers: How Ecological Dynamics Has Progressively Changed Perceptions of Skill "Acquisition" in the Sporting Habitat

Over two decades ago, Davids et al. (1994) and Handford et al. (1997) raised theoretical concerns associated with traditional, reductionist, and mechanistic perspectives of movement coordination and skill acquisition for sport scientists interested in practical applications for training designs. These seminal papers advocated an emerging consciousness grounded in an ecological approach, signaling the need for sports practitioners to appreciate the constraints-led, deeply entangled, and non-linear reciprocity between the organism (performer), task, and environment subsystems. Over two decades later, the areas of skill acquisition, practice and training design, performance analysis and preparation, and talent development in sport science have never been so vibrant in terms of theoretical modeling, knowledge generation and innovation, and technological deployment. Viewed at an ecological level of analysis, the work of sports practitioners has progressively transitioned toward the facilitation of an evolving relationship between an organism (athlete and team) and its environment (sports competition). This commentary sets out to explore how these original ideas from Davids et al. (1994) and Handford et al. (1997) have been advanced through the theoretical lens of ecological dynamics. Concurrently, we provide case study exemplars, from applied practice in high-performance sports organizations, to illustrate how these contemporary perspectives are shaping the work of sports practitioners (sport ecology designers) in practice and in performance preparation.

Characterizations of motivation and identity in medical students' reflections about challenging patient interactions

Purpose: Students' negative emotions in patient interactions can relate to their learning motivation and identity. Educators can support learning from these interactions by advocating for reflection. We explored how students, in reflection essays about emotionally difficult patient interactions that challenged their notions of professionalism, described aspects of motivation and identity. Materials and Methods: All third-year medical students on the ob-gyn clerkship complete written reflections about a "clinical situation that challenged or affirmed your professionalism." We conducted directed content analysis of essays (academic years 2014-2017) using relevant theories (self-determination, goal orientation and identity formation) based on previous work and organized the data into categories. Results: In 265 essays (of 396, 67%), students described patient interactions that challenged their notions of professionalism, of which 90% included descriptions of their emotions. When reflecting on these interactions, students described psychological needs acknowledged in self-determination theory, competence, autonomy in patient care and connection to the team. Students indicated challenges in identity when advocating for patients due to team hierarchy and evaluation concerns. Conclusions: Reflection essays about difficult patient interactions allow students to explore emotions, motivation and identity. They help educators understand whether the clinical learning environment is meeting students' needs to support learning in challenging interactions.

Learning to be a doctor: Medical students' perception of their roles in longitudinal outpatient clerkships

OBJECTIVE

To understand how medical students perceive their roles in early longitudinal primary care clerkships.

METHODS

Medical students enrolled in one of two longitudinal primary care clerkships - Education-Centered Medical Home (ECMH) or Individual Preceptorship (IP) - participated in semi-structured interviews. Interviews were recorded, transcribed, and analyzed using a grounded theory and constant comparative approach.

RESULTS

Students (N = 35) in both clerkships perceived benefits of early clinical exposure, reflecting positively on having time to interact with patients. Identified roles ranged from shadower to collaborator to diagnostician; a progression from position-centered to more patient-centered roles emerged. ECMH students also identified as health educators, care managers, and mentors. IP students described the clerkship primarily as an opportunity to acquire clinical knowledge and practice skills, expressing perceptions of being a transient "visitor" in the clinic, whereas ECMH students reported taking an active role in continuity care of patients.

CONCLUSION

Students identified benefits of early longitudinal outpatient primary care clerkships, supporting the inclusion of these experiences within medical school curricula. Clerkships with an emphasis on longitudinal and team-based care may further promote student participation in patient care and professional development.

PRACTICE IMPLICATIONS

Longitudinal, team-based early clinical experiences may best promote student involvement in patient care.

Motivation and emotion predict medical students' attention to computer-based feedback

Students cannot learn from feedback unless they pay attention to it. This study investigated relationships between the personal factors of achievement goal orientations, achievement emotions, and attention to feedback in BioWorld, a computer environment for learning clinical reasoning. Novice medical students (N = 28) completed questionnaires to measure their achievement goal orientations and then thought aloud while solving three endocrinology patient cases and reviewing corresponding expert solutions. Questionnaires administered after each case measured participants' experiences of five feedback emotions: pride, relief, joy, shame, and anger. Attention to individual text segments of the expert solutions was modelled using logistic regression and the method of generalized estimating equations. Participants did not attend to all of the feedback that was available to them. Performance-avoidance goals and shame positively predicted attention to feedback, and performance-approach goals and relief negatively predicted attention to feedback. Aspects of how the feedback was displayed also influenced participants' attention. Findings are discussed in terms of their implications for educational theory as well as the design and use of computer learning environments in medical education.

Context matters when striving to promote active and lifelong learning in medical education

WHERE DO WE STAND NOW?: In the 30 years that have passed since The Edinburgh Declaration on Medical Education, we have made tremendous progress in research on fostering 'self-directed and independent study' as propagated in this declaration, of which one prime example is research carried out on problem-based learning. However, a large portion of medical education happens outside of classrooms, in authentic clinical contexts. Therefore, this article discusses recent developments in research regarding fostering active learning in clinical contexts.

SELF-REGULATED, LIFELONG LEARNING IN MEDICAL EDUCATION

Clinical contexts are much more complex and flexible than classrooms, and therefore require a modified approach when fostering active learning. Recent efforts have been increasingly focused on understanding the more complex subject of supporting active learning in clinical contexts. One way of doing this is by using theory regarding self-regulated learning (SRL), as well as situated learning, workplace affordances, self-determination theory and achievement goal theory. Combining these different perspectives provides a holistic view of active learning in clinical contexts. ENTRY TO PRACTICE, VOCATIONAL TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT: Research on SRL in clinical contexts has mostly focused on the undergraduate setting, showing that active learning in clinical contexts requires not only proficiency in metacognition and SRL, but also in reactive, opportunistic learning. These studies have also made us aware of the large influence one's social environment has on SRL, the importance of professional relationships for learners, and the role of identity development in learning in clinical contexts. Additionally, research regarding postgraduate lifelong learning also highlights the importance of learners interacting about learning in clinical contexts, as well as the difficulties that clinical contexts may pose for lifelong learning. However, stimulating self-regulated learning in undergraduate medical education may also make postgraduate lifelong learning easier for learners in clinical contexts.

How do formative objective structured clinical examinations drive learning? Analysis of residents' perceptions

INTRODUCTION

Although several studies have explored the relationship between learning and written tests, little is understood about how performance-based examinations influence learning. The purpose of this study was to explore how a formative objective structured clinical examination (OSCE) drives learning.

METHODS

We administered surveys to residents (n = 35) at three time points to determine if and how an OSCE influenced their learning: before and immediately following the OSCE, and after the distribution of their results. Differences in quantitative responses between high- and low-performing residents and across time were compared using repeated-measures ANOVA. Thematic analysis was used to analyze narrative comments.

RESULTS

Participants' goals for the OSCE related to performance, mastery and feedback. Almost all participants reported that they had learned something from the OSCE (94%) and most participants generated learning goals after the OSCE (71%). High performers appeared to recognize the importance of content-related knowledge for scoring well before and after the OSCE, whereas low performers may have under-estimated its importance until after the examination.

DISCUSSION

Participants viewed a formative OSCE as both a hurdle to overcome (assessment of learning) and an opportunity to learn (assessment for learning). Understanding how OSCEs influence study behavior can help guide the development of assessments that promote learning.

Measuring achievement goal motivation, mindsets and cognitive load: validation of three instruments' scores

OBJECTIVE

Measurement of motivation and cognitive load has potential value in health professions education. Our objective was to evaluate the validity of scores from Dweck's Implicit Theories of Intelligence Scale (ITIS), Elliot's Achievement Goal Questionnaire-Revised (AGQ-R) and Leppink's cognitive load index (CLI).

METHODS

This was a validity study evaluating internal structure using reliability and factor analysis, and relationships with other variables using the multitrait-multimethod matrix. Two hundred and thirty-two secondary school students participated in a medical simulation-based training activity at an academic medical center. Pre-activity ITIS (implicit theory [mindset] domains: incremental, entity) and AGQ-R (achievement goal domains: mastery-approach, mastery-avoidance, performance-approach, performance-avoidance), post-activity CLI (cognitive load domains: intrinsic, extrinsic, germane) and task persistence (self-directed repetitions on a laparoscopic surgery task) were measured.

RESULTS

Internal consistency reliability (Cronbach's alpha) was > 0.70 for all domain scores except AGQ-R performance-avoidance (alpha 0.68) and CLI extrinsic load (alpha 0.64). Confirmatory factor analysis of ITIS and CLI scores demonstrated acceptable model fit. Confirmatory factor analysis of AGQ-R scores demonstrated borderline fit, and exploratory factor analysis suggested a three-domain model for achievement goals (mastery-approach, performance and avoidance). Correlations among scores from conceptually-related domains generally aligned with expectations, as follows: ITIS incremental and entity, r = -0.52; AGQ-R mastery-avoidance and performance-avoidance, r = 0.71; mastery-approach and performance-approach, r = 0.55; performance-approach and performance-avoidance, r = 0.43; mastery-approach and mastery-avoidance, r = 0.36; CLI germane and extrinsic, r = -0.35; ITIS incremental and AGQ-R mastery-approach, r = 0.34; ITIS incremental and CLI germane, r = 0.44; AGQ-R mastery-approach and CLI germane, r = 0.48 (all p < 0.001). We found no correlation between the number of task repetitions (i.e. persistence) and mastery-approach scores, r = -0.01.

CONCLUSIONS

ITIS and CLI scores had appropriate internal structures and relationships with other variables. AGQ-R scores fit a three-factor (not four-factor) model that collapsed avoidance into one domain, although relationships of other variables with the original four domain scores generally aligned with expectations. Mastery goals are positively correlated with germane cognitive load.

Graduates' Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study

PURPOSE

The authors explored affordances that contribute to participants' successful learning in longitudinal integrated clerkships (LICs).

METHOD

This dual-institutional, mixed-methods study included electronic surveys and semistructured interviews of LIC graduates who completed their core clinical (third) year of medical school. These LIC graduates took part in LICs at Harvard Medical School from 2004 to 2013 and the University of North Carolina School of Medicine-Asheville campus from 2009 to 2013. The survey questions asked LIC graduates to rate components of LICs that they perceived as contributing to successful learning. A research assistant interviewed a subset of study participants about their learning experiences. The authors analyzed aggregate data quantitatively and performed a qualitative content analysis on interview data.

RESULTS

The graduates reported multiple affordances that they perceive contributed to successful learning in their LIC. The most reported components included continuity and relationships with preceptors, patients, place, and peers, along with integration of and flexibility within the curriculum.

CONCLUSIONS

As LIC models grow in size and number, and their structures and processes evolve, learners' perceptions of affordances may guide curriculum planning. Further research is needed to investigate to what degree and by what means these affordances support learning in LICs and other models of clinical education.

Using "big data" to guide implementation of a web and mobile adaptive learning platform for medical students

BACKGROUND

Adaptive learning platforms (ALPs) can revolutionize medical education by making learning more efficient, but their potential has not been realized because students do not use them persistently.

METHODS

We applied educational data mining methods to study United States medical students who used an ALP called Osmosis ( www.osmosis.org ) from 1 August 2014 to 31 July 2015. Multivariate logistic regressions modeled persistence on Osmosis as the dependent variable and Osmosis-collected variables as predictors.

RESULTS

The 6787 students included in our analysis responded to a total of 887,193 items, with 2138 (31.5%) using Osmosis persistently. Number of items per student, mobile device use, subscription payment, and group membership were independently associated with persisting (p < 0.001 in all models). Persistent users rated quality more favorably (p < 0.01) but were not more confident in answer selections (p = 0.80). While persisters were more accurate than non-persisters (55% (SD 18%) vs 52% (SD 22%), p < 0.001), after adjusting for number of items, lower accuracy was associated with persistent use (OR 0.93 [95% CI 0.90-0.97], p < 0.01).

CONCLUSIONS

Our study of a large sample of U.S. medical students illustrates big data medical education research and provides guidance for improving implementation of ALPs and further investigation.

Improving clerkship preparedness: a hospital medicine elective for pre-clerkship students

BACKGROUND

Medical students often struggle to apply their nascent clinical skills in clerkships. While transitional clerkships can orient students to new roles and logistics, students may benefit from developing clinical skills in inpatient environments earlier in their curriculum to improve readiness for clerkships.

INTERVENTION

Our four- to six-session elective provides pre-clerkship students with individualized learning in the inpatient setting with the aim of improving clerkship preparedness. Students work one-on-one with faculty who facilitate individualized learning through mentoring, deliberate practice, and directed feedback. Second-year medical students are placed on an attending-only, traditionally 'non-teaching' service in the hospital medicine division of a Veterans Affairs (VA) hospital for half-day sessions. Most students self-select into the elective following a class-wide advertisement. The elective also accepts students who are referred for remediation of their clinical skills.

OUTCOME

In the elective's first two years, 25 students participated and 47 students were waitlisted. We compared participant and waitlisted (non-participant) students' self-efficacy in several clinical and professional domains during their first clerkship. Elective participants reported significantly higher clerkship preparedness compared to non-participants in the areas of physical exam, oral presentation, and formulation of assessments and plans.

CONCLUSIONS

Students found the one-on-one feedback and personalized attention from attending physicians to be a particularly useful aspect of the course. This frequently cited benefit points to students' perceived needs and the value they place on individualized feedback. Our innovation harnesses an untapped resource - the hospital medicine 'non-teaching' service - and serves as an attainable option for schools interested in enhancing early clinical skill-building for all students, including those recommended for remediation.

ABBREVIATIONS

A&P: Assessment and plan; H&P: History and physical; ILP: Individual learning plan.