Remediating lapses in professionalism among undergraduate pre-clinical medical students in an Asian Institution: a multimodal approach

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review update: BEME Guide No. 85

BACKGROUND

Clinical teachers often struggle to record trainee underperformance due to lacking evidence-based remediation options.

OBJECTIVES

To provide updated evidence-based recommendations for addressing academic difficulties among undergraduate and postgraduate medical learners.

METHODS

A systematic review searched databases including MEDLINE, CINAHL, EMBASE, ERIC, Education Source, and PsycINFO (2016-2021), replicating the original Best Evidence Medical Education 56 review strategy. Original research/innovation reports describing intervention(s) for medical learners with academic difficulties were included. Data extraction used Michie's Behaviour Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraised used the Mixed Methods Appraisal Tool (MMAT). Authors synthesized extracted evidence by adapting GRADE approach to formulate recommendations.

RESULTS

Eighteen articles met the inclusion criteria, primarily addressing knowledge (66.7%), skills (66.7%), attitudinal problems (50%) and learner's personal challenges (27.8%). Feedback and monitoring was the most frequently employed BCT. Study quality varied (MMAT 0-100%). We identified nineteen interventions (UG: n = 9, PG: n = 12), introducing twelve new thematic content. Newly thematic content addressed contemporary learning challenges such as academic procrastination, and use of technology-enhanced learning resources. Combined with previous interventions, the review offers a total dataset of 121 interventions.

CONCLUSION

This review offers additional evidence-based interventions for learners with academic difficulties, supporting teaching, learning, faculty development, and research efforts.

Development of a hybrid undergraduate portfolio for the AETCOM module

Background

A structured Attitude Ethics and Communication (AETCOM) module for undergraduates exists. For ensuring that the module achieves what it is intended to achieve, there was a felt need to develop a learning portfolio with an emphasis on reflections and with a scope for assessment.

Methods

The AETCOM module by NMC has laid out objectives, lesson plans, and case-based scenarios. Hybrid portfolio development was necessary to align the sessions to the objectives and lesson plans and to help students capture their learning process with self-reflection, and at the same time, ensure the scope of assessment of these activities. Hence, writing reflections was considered the most important step. Measures were taken to train students in writing reflections, and faculty development workshops were also conducted. An evaluation was done using Kirkpatrick model level I-III using student's feedback form, scores of rubric matrix for assessment of reflections and one-on-one interaction with students by trained faculty. Faculty perspectives on portfolio development were collected.

Results

A significant improvement in students' self-assessment scores on AETCOM module was seen (p <0.05). An assessment of reflections using a rubric matrix showed that all the students reached at least grade B by the end of three months. More than 90% of faculty members felt that the faculty is vital for assessing AETCOM.

Conclusion

The development of a hybrid portfolio for AETCOM requires faculty development and special sessions for students on writing reflections. The hybrid portfolio provides the learner to self reflect, and a rubric matrix can be used to assess reflections.

The Importance of Learning with Patients: Post-Pandemic Takeaways on Learning Professionalism in Clinical Settings

Background

Public demands for high-quality healthcare require medical schools to ensure that physicians attain various competencies, including professionalism and humanism. This can be accomplished through various interactions and socialisations within the healthcare community. These meaningful learning experiences become more critical as students face unpredictable learning opportunities in clinical settings. However, professional development focuses on lapses, remediation and knowledge retention rather than its practice. To nurture professional and humanistic physicians, this study explores how medical students perceive learning professionalism in clinical settings.

Methods

This is a qualitative phenomenology study involving medical students in clinical rotations at the Faculty of Medicine Universitas Indonesia. Respondents were chosen through a purposive sampling method that considered their gender and clinical years. Data were collected through focus group discussions (FGDs) and thematic analysis was used.

Results

Three FGDs were conducted with 31 clinical students. Learning professionalism in clinical settings presents challenges, including the hidden curriculum (HC), limited exposure to patients and the clinical learning environment because of the social restrictions caused by the COVID-19 pandemic. The tailored strategy to learn professionalism in the clinical learning environment was more teacher-driven, including role modelling, debriefing, providing feedback and teaching context-specific knowledge on professionalism, followed by patient interactions.

Conclusion

The significance of students' interactions with the clinical learning environment, especially with patients and clinical teachers as role models, is the key to learning professionalism in clinical settings. This finding is an important takeaway in curriculum design for professionalism.

Professional Identity of Pakistani Veterinary Students: Conceptualization and Negotiation

Most work on the professional identity of veterinary and medical professionals has been conceptualized in the USA and Europe. It reports professional identity formation to be highly individualized, triggered by experiences of identity distress, and identity negotiation strategies to be generally focused around personal reflection. However, within Asia, important sociocultural differences exist that might influence professional identity and its development. Societal values may take precedence over individual ones, and some cultures consider the veterinary profession as stigmatized. With this background, we seek to understand professional identity and its construction in Pakistani veterinary students. We selected five students through purposive sampling and invited them for narrative interviews. Social identity theory and Maslow's theory of hierarchy of needs predominantly contributed to the theoretical framework, which together with principles of social phenomenology and narrative analysis informed qualitative analysis of the transcribed interviews using an in-depth approach. We found that students' professional identity was predominantly socially constructed, though their sense of their identity was not very well developed. Role models, social stigma, professional socialization in clinical settings, gender, and to some extent, cultural interpretations of religious messages seemed to mediate professional identity development. Students responded differently to their understanding of professional stigma, making sense of stigma through strategies such as denial or internalization. Since Pakistani veterinary students experience social and personal values differently compared to those from predominantly individualistic cultures, identity formation through reflecting on personal values may be less effective than strategies that emphasize social learning and beliefs.

Assessing professional identity formation (PIF) amongst medical students in Oncology and Palliative Medicine postings: a SEBA guided scoping review

BACKGROUND

Introduction to a multi-professional team who are working and caring for the dying, and facing complex moral and ethical dilemmas during Oncology and Palliative Medicine postings influence a medical student's professional identity formation (PIF). However, limited appreciation of PIF, inadequate assessments and insufficient support jeopardise this opportunity to shape how medical students think, feel and act as future physicians. To address this gap, a systematic scoping review (SSR) of PIF assessment methods is proposed.

METHODS

A Systematic Evidence-based Approach (SEBA) guided SSR of assessments of PIF in medical schools published between 1^st January 2000 and 31^st December 2021 in PubMed, Embase, ERIC and Scopus databases was carried out. Included articles were concurrently content and thematically analysed using SEBA's Split Approach and the themes and categories identified were combined using SEBA's Jigsaw Perspective. The review hinged on the following questions: "what is known about the assessment of professional identity formation amongst medical students?", "what are the theories and principles guiding the assessment of professional identity formation amongst medical students?", "what factors influence PIF in medical students?", "what are the tools used to assess PIF in medical students?", and "what considerations impact the implementation of PIF assessment tools amongst medical students?".

RESULTS

Two thousand four hundred thirty six abstracts were reviewed, 602 full-text articles were evaluated, and 88 articles were included. The 3 domains identified were 1) theories, 2) assessment, and 3) implementation in assessing PIF. Differing attention to the different aspects of the PIF process impairs evaluations, jeopardise timely and appropriate support of medical students and hinder effective implementation of PIF assessments.

CONCLUSION

The Krishna-Pisupati model combines current theories and concepts of PIF to provide a more holistic perspective of the PIF process. Under the aegis of this model, Palliative Care and Oncology postings are envisaged as Communities of Practice influencing self-concepts of personhood and identity and shaping how medical students see their roles and responsibilities as future physicians. These insights allow the forwarding of nine recommendations to improve assessments of PIF and shape the design of a PIF-specific tool that can direct timely and personalized support of medical students.

Post graduate remediation programs in medicine: a scoping review

BACKGROUND

Recognizing that physicians may struggle to achieve knowledge, skills, attitudes and or conduct at one or more stages during their training has highlighted the importance of the 'deliberate practice of improving performance through practising beyond one's comfort level under guidance'. However, variations in physician, program, contextual and healthcare and educational systems complicate efforts to create a consistent approach to remediation. Balancing the inevitable disparities in approaches and settings with the need for continuity and effective oversight of the remediation process, as well as the context and population specific nature of remediation, this review will scrutinise the remediation of physicians in training to better guide the design, structuring and oversight of new remediation programs.

METHODS

Krishna's Systematic Evidence Based Approach is adopted to guide this Systematic Scoping Review (SSR in SEBA) to enhance the transparency and reproducibility of this review. A structured search for articles on remediation programs for licenced physicians who have completed their pre-registration postings and who are in training positions published between 1st January 1990 and 31st December 2021 in PubMed, Scopus, ERIC, Google Scholar, PsycINFO, ASSIA, HMIC, DARE and Web of Science databases was carried out. The included articles were concurrently thematically and content analysed using SEBA's Split Approach. Similarities in the identified themes and categories were combined in the Jigsaw Perspective and compared with the tabulated summaries of included articles in the Funnelling Process to create the domains that will guide discussions.

RESULTS

The research team retrieved 5512 abstracts, reviewed 304 full-text articles and included 101 articles. The domains identified were characteristics, indications, frameworks, domains, enablers and barriers and unique features of remediation in licenced physicians in training programs.

CONCLUSION

Building upon our findings and guided by Hauer et al. approach to remediation and Taylor and Hamdy's Multi-theories Model, we proffer a theoretically grounded 7-stage evidence-based remediation framework to enhance understanding of remediation in licenced physicians in training programs. We believe this framework can guide program design and reframe remediation's role as an integral part of training programs and a source of support and professional, academic, research, interprofessional and personal development.

"To obey or not to obey" - Medical students' response towards professional dilemmas in a hierarchical and collectivist culture

BACKGROUND

Clinical clerkship programme in medical schools were developed to provide students with direct interactions with patients and observe clinical teachers in practice. However, professional dilemmas are prone to occur due to the nature of experiential learning. Several studies across different cultures showed that medical students responded differently towards professional dilemma.

AIMS

This study aims to explore how medical students respond to professional dilemmas occurred during their clinical clerkships and to what extent culture influences the responses.

METHOD

A qualitative descriptive approach was used in this study. We conducted four focus group discussions with final year medical students who were selected using maximum variety sampling method. Thematic analysis was conducted following the transcription of the focus groups.

RESULTS

We identified the impact of dilemmas on students' emotions and concerns, students' responses towards professional dilemmas, and factors affecting responses to dilemmas in clinical clerkship, which confirmed that cultures played roles in how students responded towards professional dilemmas.

CONCLUSION

This study has identified that culture, to some extent, influenced the way students responded to professional dilemmas. Therefore, it is paramount to develop a conducive and culturally sensitive educational environment and students' ability to learn from professional dilemma experienced in the workplace for developing their professional identity.

A Scoping Review of Professional Identity Formation in Undergraduate Medical Education

BACKGROUND

Professional identity formation (PIF) in medical students is a multifactorial phenomenon, shaped by ways that clinical and non-clinical experiences, expectations and environmental factors merge with individual values, beliefs and obligations. The relationship between students' evolving professional identity and self-identity or personhood remains ill-defined, making it challenging for medical schools to support PIF systematically and strategically. Primarily, to capture prevailing literature on PIF in medical school education, and secondarily, to ascertain how PIF influences on medical students may be viewed through the lens of the ring theory of personhood (RToP) and to identify ways that medical schools support PIF.

METHODS

A systematic scoping review was conducted using the systematic evidence-based approach. Articles published between 1 January 2000 and 1 July 2020 related to PIF in medical students were searched using PubMed, Embase, PsycINFO, ERIC and Scopus. Articles of all study designs (quantitative and qualitative), published or translated into English, were included. Concurrent thematic and directed content analyses were used to evaluate the data.

RESULTS

A total of 10443 abstracts were identified, 272 full-text articles evaluated, and 76 articles included. Thematic and directed content analyses revealed similar themes and categories as follows: characteristics of PIF in relation to professionalism, role of socialization in PIF, PIF enablers and barriers, and medical school approaches to supporting PIF.

DISCUSSION

PIF involves iterative construction, deconstruction and inculcation of professional beliefs, values and behaviours into a pre-existent identity. Through the lens of RToP, factors were elucidated that promote or hinder students' identity development on individual, relational or societal levels. If inadequately or inappropriately supported, enabling factors become barriers to PIF. Medical schools employ an all-encompassing approach to support PIF, illuminating the need for distinct and deliberate longitudinal monitoring and mentoring to foster students' balanced integration of personal and professional identities over time.

Self-Reported Academic Misconduct among Medical Students: Perception and Prevalence

Academic integrity is the basis of an education system and must be taught as an ethical behavior during academic training. Students who reflect honesty and truthfulness during the academic years are more likely to follow this path, develop professional integrity, and thus become responsible and dependable professionals. Here, we determine the prevalence of academic lapses among medical students by a cross-sectional descriptive survey based on a self-assessment questionnaire. Students' perception of 37 behaviors comprising five domains, plagiarism, indolence, cheating, disruptive behavior, and falsifying data, were explored. A high percentage of students (83%) indicated that all 37 behaviors constitute misconduct. Approximately 65% of students thought that their fellow students were involved in dishonest behaviors, and 34% answered that they were indulged in some form of misconduct. Content analysis identified some prevalent behaviors such as doing work for another student (82.5%), getting information from the students who already took the exam (82.5%), copying the answer from neighbors (79%), and marking attendance for absent friends (74.5%). Multiple regression analysis points out that future indulgence in a behavior is significantly (p ≤ 0.5) correlated with understanding a behavior as wrong, perceiving that others do it and whether one has already indulged in it. This study can serve as a diagnostic tool to analyze the prevalence of misconduct and a foothold to develop the medical school system's ethical guidelines.

Good Knowledge but Poor Practice Toward COVID-19 Among Indonesian Youth

COVID-19 cases have been increasing among young people as they are often considered to have low compliance with COVID-19 preventive measures. Given that challenge, there have been limited studies exploring this issue. Through a nationwide online survey, we assessed knowledge, attitudes, and practice toward COVID-19 among Indonesian youth and potential interventions to improve their behavior. We found that Indonesian youth had good knowledge of COVID-19, but their practices remained poor. Noncompliance was more frequent in males, students in Islamic high schools, those residing outside the Java-Bali islands, and students living in a lower income household. Significant barriers included lack of regulation, difficulties in avoiding crowds, and soap shortage. Their exposure to and trust in the internet was very high. These findings highlight that youth compliance with COVID-19 preventive measures should be improved by reducing barriers, collaborating actively with young people, and encouraging effective campaigns together with social media influencers.

COVID-19: Impact on undergraduate nursing education in Sri Lanka

“Novel Corona Virus” (COVID-19) is a new infectious disease spreading all around the world that has a globally significant morbidity and mortality at present. Nurses as frontline care providers in hospitals and community are exposed to a major risk. This brief report aims at providing an overview of COVID-19 impacts on Sri Lanka and to highlight educational implications from the perspective of nursing degree programs. The major impacts of COVID-19 on nursing education were unequal access to online distance learning, disruption of academic calendars, cancellation of clinical placements, teaching and learning gap, lack of facilities for online learning, disruption towards professional development, and inability to conduct proper clinical assessments and standard operationalization procedures. It suggests that higher education institutions should take actions to provide material support for students from low-income households to close the gap between teaching and learning and training academics on different online teaching and learning strategies and assessments.

Exploring medical students' professional identity formation through written reflections during the COVID-19 pandemic

Background: Disruptions due to the COVID-19 pandemic have forced medical schools around the world to adapt. Major changes in curriculum delivery during the pandemic have impacted medical students' professional development. We assess undergraduate medical students' adaptations and Professional Identity Formation (PIF) by exploring their written reflections. Methods: This phenomenology study analyzes undergraduate medical students' written reflections. We perform a thematic analysis to identify emerging themes. Results: We purposively selected 80 written reflections, considering the students' year of study, gender, GPA, and education stage (preclinical or clinical). Three themes emerged: students' adaptation processes and coping strategies in facing the pandemic; their adaptation processes for learning; and their perceived roles as medical students during the pandemic. Conclusions: Adaptive coping mechanisms were implemented by the medical students in this study. The socialization processes that promote professional identity formation may change due to the tremendous disruption wrought by the pandemic; this has prompted our investigation of students' roles and various ways of interacting with role models. We highlight the importance of the medical school supporting students' adaptations and professional identity formation during this pandemic.

Needs Assessment for Supports to Promote Pediatric Clinical Research Using an Online Survey of the Japanese Children's Hospitals Association

INTRODUCTION

Infrastructure and the capacity to conduct clinical research in pediatrics have not been fully established in Japan. To elucidate the physicians' perspectives on clinical research, level of experience, existing barriers, and requests for support, we conducted a survey at 34 children's hospitals in Japan.

METHODS

In January 2016, an online survey with 13 questions was sent to approximately 2000 physicians working in 34 pediatric hospitals belonging to the Japanese Association of Children's Hospitals and Related Institutions.

RESULTS

Of the 360 respondents, 318 (88.3%) had presentations at academic conferences, and 261 (72.5%) had publications in academic journals, in the previous year. The most common study designs of clinical research conducted were case reports and case series. The most requested supports were for statistical analysis, followed by study design, grant application, and English-language editing. Younger physicians were more likely to prefer educational lectures (p < 0.001), whereas experienced physicians were more likely to request support for conducting statistical analysis (p = 0.002). Whereas physicians who had ever led a clinical trial requested support for the development of study protocol (p = .013), those without this experience preferred support for literature review (p = .002) and consultation services for study design (p = .027).

CONCLUSIONS

The requests for supports were different, depending on the physicians' years after graduation and experience level in clinical research. In order to enhance clinical research in pediatrics, it is essential to provide appropriate types and levels of educational and support programs.

Remediating professionalism lapses in medical students and doctors: A systematic review

CONTEXT

A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors.

METHODS

Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist.

RESULTS

A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation.

CONCLUSIONS

The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

Extracurricular Activities in Higher Education and the Promotion of Reflective Learning for Sustainability

The objective of higher education institutions is to integrate reflective learning that contributes to the development of a greater awareness among individuals of the importance of facing the 21st century’s sustainability challenges. This paper analyzes the impact of an extracurricular volunteer activity in Tangier, Morocco in the development of student reflection at a Spanish university. To this end, two objectives were proposed: (1) to explore the students’ primary reflections of the experience, and (2) analyze the students’ perceptions of the importance of participating in the experience in order to develop reflective learning. In the study, in-depth interviews were conducted with 23 students who participated in the volunteer activity. Data analysis was carried out using Iramuteq software to conduct a descending hierarchical classification (DHC), and MAXQDA software to conduct a constant comparison analysis. This research highlights the value of voluntary extracurricular activities in the development of reflections that guide change in the beliefs, attitudes, and daily behaviors of students that ultimately result in sustainability. Due to this, not only is it considered essential that students participate in social projects, but also that they undertake these projects with peers and instructors who can create environments of support and trust.

Failure of faculty to fail failing medical students: Fiction or an actual erosion of professional standards?

OBJECTIVES

Literature has shown that some assessors assign passing grades to medical students who, in fact, should not have passed. This inability of the faculty to fail underperforming students can jeopardise the reputation of professional programs, be it in the medical field or beyond. Simultaneously, weak students become incompetent physicians and, thus, endanger the community they serve. The impetus for conducting this systematic review was to identify barriers to faculty in failing struggling medical students.

METHODS

The databases of MEDLINE, Scopus, Wiley online library, Cochrane library, OVID, Taylor and Francis, CINAHL, Springer link, ProQuest, and ISI Web of knowledge were searched using Medical Subject Headings (MeSH) terms 'Faculty failure' AND 'Failing students' AND 'Failure to fail' OR 'Assessment'. The data were synthesised, and the results were analysed.

RESULTS

This search showed a wealth of barriers to faculty contributing to a 'failure to fail' such as their concerns about legal action and an appeals process; the stress of failing students; a lack of knowledge about proper documentation; unavailability of support, resources, and offices for faculty; absence of administrative guidelines; and complex dismissal procedures discouraging the faculty from failing students.

CONCLUSION

Institutional faculty development programs and training workshops should facilitate the education of supervisors and assessors for timely evaluation and regular documentation of trainee assessment. The provision of legal advice in cases of appeal and professional support by the resource and support office is emphasised.