Is there a way for clinical teachers to assist struggling learners? A synthetic review of the literature

Unravelling epistemic injustice in medical education: The case of the underperforming learner

CONTEXT

Epistemic injustice refers to a wrong done to someone in their capacity as a knower. While philosophers have detailed the pervasiveness of this issue within healthcare, it is only beginning to be discussed by medical educators. The purpose of this article is to expand the field's understanding of this concept and to demonstrate how it can be used to reframe complex problems in medical education.

METHODS

After outlining the basic features of epistemic injustice, we clarify its intended (and unintended) meaning and detail what is required for a perceived harm to be named an epistemic injustice. Using an example from our own work on introversion in undergraduate medical education, we illustrate what epistemic injustice might look like from the perspectives of both educators and students and show how the concept can reorient our perspective on academic underperformance.

RESULTS

Epistemic injustice results from two things: (1) social power dynamics that give some individuals control over others, and (2) identity prejudice that is associated with discriminatory stereotypes. This can lead to one, or both, forms of epistemic injustice: testimonial and hermeneutical. Our worked example demonstrates how medical educators can be unaware of when and how epistemic injustice is happening, yet the effects on students' well-being and sense of selves can be profound. Thinking about academic underperformance with epistemic injustice in mind can reveal an emphasis within current educational practices on diagnosing learning deficiencies, to the detriment of holistically representing its socially constructed and structural nature.

CONCLUSIONS

This article builds upon recent calls to recognise epistemic injustice in medical education by clarifying its terminology and intended use and providing in-depth application and analysis to a particular case: underperformance and the introverted medical student. Equipped with a more sophisticated understanding of the term, medical educators may be able to re-conceptualise long-standing issues including, but also beyond, underperformance.

'We're like Spider-Man; with great power comes great responsibility': Coaches' experiences supporting struggling medical students

BACKGROUND

Medical students can experience a range of academic and non-academic struggles. Coaching is a valuable strategy to support learners, but coaches describe working with struggling learners as taxing. Transformative learning theory (TLT) provides insights into how educators grow from challenging experiences to build resilience. This study explores how coaches evolve as educators through supporting struggling students.

METHODS

This qualitative study grounded in an interpretivist paradigm used interviews of longitudinal medical student coaches at two academic institutions. Interviews, using TLT as a sensitizing concept, explored coaches' experience coaching struggling learners. We performed thematic analysis.

RESULTS

We interviewed 15 coaches. Coaches described supporting students through multi-faceted struggles which often surprised the coach. Three themes characterized coaches' experiences: personal responsibility, emotional response, and personal learning. Coaches shouldered high personal responsibility for learners' success. For some, this burden felt emotional, raised parental instincts and questions about maintaining boundaries with learners. Coaches evolved their coaching approach, challenged biases, and built skills. Coaches learned to better appreciate the learner point of view and employ resources to support students.

DISCUSSION

Through navigating learner struggles, educators can gain self-efficacy, learn to understand learners' perspectives, and evolve their coaching approach to lessen their personal emotional burden through time.

Thresholds of becoming: an exploration of threshold concepts as a means to support professional identity formation in competency-based curricula

Inherent in every clinical preceptor's role is the ability to understand the learning needs of individual trainees, enabling them to meet their potential. Competency-based medical education frameworks have been developed to this end, but efforts to identify behaviours and activities that define competence are based on mapping knowledge, skills and ability, which can be difficult to integrate into a comprehensive picture of who the trainee is becoming. Professional identity formation, in contrast, prioritizes attention to who trainees are becoming, but provision of detailed guidance to preceptors on how to best support this form of development is challenging. The tension that results limits our ability to optimally support learners as strengths in competency development may mask professional identity development gaps and vice versa. To address this tension, this paper examines how the theory of threshold concepts - troublesome ideas that, once appreciated, fundamentally change how you understand and approach a particular activity - can shine light on professional identity formation and its relationship with developing competence. The recognition and identification of threshold concepts is offered as a means to improve our ability to identify, discuss and support behaviours and actions that impact the learner's capacity to act competently as they develop their identity at various stages of training.

Accuracy of Entrustment-Based Assessment: Implications for Programs and Patients

Background Although entrustment-supervision ratings are more intuitive compared to other rating scales, it is not known whether their use accurately assesses the appropriateness of care provided by a resident. Objective To determine the frequency of incorrect entrustment ratings assigned by faculty and whether accuracy of an entrustment-supervision scale differed by resident performance when the scripted resident performance level is known. Methods Faculty participants rated standardized residents in 10 videos using a 4-point entrustment-supervision scale. We calculated the frequency of rating a resident incorrectly. We performed generalizability (G) and decision (D) studies for all 10 cases (768 ratings) and repeated the analysis using only cases with an entrustment score of 2. Results The mean score by 77 raters for all videos was 2.87 (SD=0.86) with a mean of 2.37 (SD=0.72), 3.11 (SD=0.67) and 3.78 (SD=0.43) for the scripted levels of 2, 3, and 4. Faculty ratings differed from the scripted score for 331of 768 (43%) ratings. Most errors were ratings higher than the scripted score (223, 67%). G studies estimated the variance proportions of rater and case to be 4.99% and 54.29%. D studies estimated that 3 raters would need to watch 10 cases. The variance proportion of rater was 8.5% when the analysis was restricted to level 2 entrustment, requiring 15 raters to watch 5 cases. Conclusions Participants underestimated residents' potential need for greater supervision. Overall agreement between raters and scripted scores were low.

WR, Farrell SE, Hundert EM, Dalrymple JL, Goldhamer MEJ. A pilot clinical skills coaching program to reimagine remediation: a cohort study

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.

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.

Characterization of Clinical Skills Remediation: A National Survey of Medical Schools

OBJECTIVES

Clinical skills instruction is a standard part of medical school curricula, but how institutions address learners who struggle in this area is less clear. Although recommendations for the remediation of clinical skills at an institutional level have been published, how these recommendations are being implemented on a national scale is unknown. In this descriptive study, we characterize current clinical skills remediation practices at US medical schools and US-accredited Caribbean medical schools.

METHODS

We conducted a cross-sectional survey of medical educators who work with struggling students. From March 24, 2020 to April 9, 2020, the Directors of Clinical Skills Remediation Working Group conducted an e-mail survey incorporating four aspects of remediation program design and function: identification, assessment, active remediation, and ongoing evaluation.

RESULTS

In total, 92 individuals representing 45 institutions provided descriptive information about their respective remediation programs. The majority of respondents have a formal process of identifying (75%) and assessing (86%) students who are identified as struggling with clinical skills, but lack a standardized method of categorizing deficits. Fewer institutions have a standardized approach to active remediation and ongoing evaluation of struggling learners. Fifty-two percent of institutions provide training to faculty involved in the remediation process.

CONCLUSIONS

Although most institutions are able to identify struggling students, they lack a standardized approach to intervene. Remediation effectiveness is limited by a lack of student buy-in and institutional time, expertise, and resources. These findings highlight the need for more formalized structure and standardization in remediation program design and implementation.

Remediation Programs for Regulated Health Care Professionals: A Scoping Review

PURPOSE

Clinical competence is essential for providing safe, competent care and is regularly assessed to ensure health care practitioners maintain competence. When deficiencies in competence are identified, practitioners may undergo remediation. However, there is limited evidence regarding the effectiveness of remediation programs. The purpose of this review is to examine the purpose, format, and outcomes of remediation programs for regulated health care practitioners.

METHODS

All six stages of the scoping review process as recommended by Levac et al were undertaken. A search was conducted within MEDLINE, Embase, CINAHL, ERIC, gray literature databases, and websites of Canadian provincial regulatory bodies. Emails were sent to Registrars of Canadian regulatory bodies to supplement data gathered from their websites.

RESULTS

A total of 14 programs were identified, primarily for physicians (n = 8). Reasons for remediation varied widely, with some programs identifying multiple reasons for referral such as deficiencies in recordkeeping (n = 7) and clinical skills (n = 6). Most programs (n = 9) were individualized to address specific deficiencies in competence. The process of remediation followed three stages: (1) assessment, (2) active remediation, and (3) reassessment. Most programs (n = 12) reported that remediation was effective in improving competence.

CONCLUSIONS

Regulatory bodies should consider implementing individualized remediation programs to ensure that clinicians' deficiencies in competence are addressed effectively. Further research is indicated, using reliable and valid outcome measures to assess competence immediately after remediation programs and beyond.

Emotion in remediation: A scoping review of the medical education literature

OBJECTIVES

Remediation can be crucial and high stakes for medical learners, and experts agree it is often not optimally conducted. Research from other fields indicates that explicit incorporation of emotion improves education because of emotion's documented impacts on learning. Because this could present an important opportunity for improving remediation, we aimed to investigate how the literature on remediation interventions in medical education discusses emotion.

METHODS

The authors used Arksey and O'Malley's framework to conduct a scoping literature review of records describing remediation interventions in medical education, using PubMed, CINAHL Complete, ERIC, Web of Science and APA PsycInfo databases, including all English-language publications through 1 May 2020 meeting search criteria. They included publications discussing remediation interventions either empirically or theoretically, pertaining to physicians or physician trainees of any level. Two independent reviewers used a standardised data extraction form to report descriptive information; they reviewed included records for the presence of mentions of emotion, described the mentions and analysed results thematically.

RESULTS

Of 1644 records, 199 met inclusion criteria and were reviewed in full. Of those, 112 (56%) mentioned emotion in some way; others focused solely on cognitive aspects of remediation. The mentions of emotion fell into three themes based on when the emotion was cited as present: during regular coursework or practice, upon referral for remediation and during remediation. One-quarter of records (50) indicated potential intentional incorporation of emotion into remediation programme design, but they were non-specific as to how emotions related to the learning process itself.

CONCLUSION

Even though emotion is omnipresent in remediation, medical educators frequently do not factor emotion into the design of remediation approaches and rarely explicitly utilise emotion to improve the learning process. Applications from other fields may help medical educators leverage emotion to improve learning in remediation, including strategies to frame and design remediation.

Optimising the delivery of remediation programmes for doctors: A realist review

CONTEXT

Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety.

METHOD

We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs).

RESULTS

A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection.

CONCLUSION

Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

Exploring attributes of high-quality clinical supervision in general practice through interviews with peer-recognised GP supervisors

BACKGROUND

Clinical supervision in general practice is critical for enabling registrars (GP trainees) to provide safe medical care, develop skills and enjoy primary care careers. However, this largely depends on the quality of supervision provided. There has been limited research describing what encompasses quality within GP clinical supervision, making it difficult to promote best practice. This study aimed to explore the attributes of high-quality clinical supervision for GP registrars.

METHODS

In 2019-20, 22 semi-structured interviews were conducted with GP supervisors who were peer-nominated as best practice supervisors, by Regional GP Training Organisations and GP Colleges in Australia. Purposeful sampling sought respondents with diverse characteristics including gender and career stage, practice size, state/territory and rurality. Interviews were conducted by video-consultation and recorded. De-identified transcripts were independently coded using iterative, inductive thematic analyses to derive themes that reflected quality in GP supervision.

RESULTS

Seven themes emerged. Participants understood the meaning of quality supervision based on their experience of being supervised when they were a registrar, and from reflecting and learning from other supervisors and their own supervision experiences. Quality was reflected by actively structuring GP placements to optimise all possible learning opportunities, building a secure and caring relationship with registrars as the basis for handling challenging situations such as registrar mistakes. Quality also encompassed sustaining and enhancing registrar learning by drawing on the input of the whole practice team who had different skills and supervision approaches. Strong learner-centred approaches were used, where supervisors adjusted support and intervention in real-time, as registrar competence emerged in different areas. Quality also involved building the registrar's professional identity and capabilities for safe and independent decision-making and encouraging registrars to reflect on situations before giving quality feedback, to drive learning.

CONCLUSIONS

This study, although exploratory, provides a foundation for understanding the quality of clinical supervision in general practice, from the perspective of peer-recognised GP supervisors. Understanding and adopting quality within GP supervision may be improved by GPs sharing exemplars of best practice and having opportunities for professional reflection. The findings could be used as a point of reference for devising GP supervisor curriculum, resources and professional development activities.

Management of residents in difficulty in a Swiss general internal medicine outpatient clinic: Change is necessary!

AIMS OF THE STUDY

Residents in difficulty are a major cause for concern in medical education, with a prevalence of 7-15%. They are often detected late in their training and cannot make use of remediation plans. Nowadays, most training hospitals in Switzerland do not have a specific program to identify and manage residents in difficulty. The aim of the study was to explore the challenges perceived by physicians regarding the process of identifying, diagnosing, and supporting residents in difficulty in a structured and programmatic way. We explored perceptions of physicians at different hierarchical levels (residents (R), Chief residents (CR), attending physicians (A), Chief Physician (CP)) in order to better understand these challenges.

METHODS

We conducted an exploratory qualitative study between December 2015 and July 2016. We asked volunteers from the Primary Care Division of the Geneva University Hospitals to partake to three focus groups (with CR, A, R) and one interview with the division's CP. We transcribed, coded, and qualitatively analyzed the three focus groups and the interview, using a content thematic approach and Fishbein's conceptual framework.

RESULTS

We identified similarities and differences in the challenges of the management of residents in difficulty on a programmatic way amongst physicians of different hierarchical levels. Our main findings: Supervisors (CR, A, CP) have good identification skills of residents in difficulty, but they did not put in place systematic remediation strategies.Supervisors (CR, A) were concerned about managing residents in difficulty. They were aware of the possible adverse effects on patient care, but "feared to harm" resident's career by documenting a poor institutional assessment.Residents "feared to share" their own difficulties with their supervisors. They thought that it would impact their career negatively.The four physician's hierarchical level reported environmental constraints (lack of funding, time constraint, lack of time and resources…).

CONCLUSION

Our results add two perspectives to specialized recommendations regarding the implementation of remediation programs for residents in difficulty. The first revolves around the need to identify and fully understand not only the beliefs but also the implicit norms and the feeling of self-efficacy that are shared by teachers and that are likely to motivate them to engage in the management of residents in difficulty. The second emphasizes the importance of analyzing these elements that constitute the context for a change and of identifying, in close contact with the heads of the institutions, which factors may favor or hinder it. This research action process has fostered awareness and discussions at different levels. Since then, various actions and processes have been put in place at the Faculty of Medicine in Geneva.

Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

Background

An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice.

Objectives

To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.

Design

A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group.

Review methods

Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations.

Results

A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection.

Limitations

Limitations were the low quality of included literature and limited number of UK-based studies.

Future work

Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS.

Study registration

This study is registered as PROSPERO CRD42018088779.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

Remediation for surgical trainees: recommendations from a narrative review

BACKGROUND

Remediation involves formalized support for surgical trainees with significant underperformance to return to expected standards. There is a need to understand current evidence of remediation for surgical trainees to inform practice and justify investment of resources.

METHODS

Following the principles of a systematic review, we conducted a narrative analysis to make recommendations for remediation of underperforming surgical trainees.

RESULTS

From a review of 55 articles on remediation of trainees in medical and surgical sub-specialities, we have identified system and process level recommendations. Remediation is reported as long-term, complex and resource-intensive. Establishing a defined and standardized remediation framework enables co-ordination of multi-modal interventions. System level recommendations aim to consolidate protocols via developing better assessment, intervention and re-evaluation modalities whilst also strengthening support to supervisors conducting the remediation. Process level recommendations should be tailored for the specific needs of each trainee, aiming to be proactive with interventions within a programmatic framework. Regular reassessment is required, and long-term follow-up shows that remediation efforts are often successful.

CONCLUSION

While remediation within a programmatic framework is complex, it is often a successful approach to return surgical trainees to their expected standard. Future directions involve applying learning theories, encouraging research methods and to develop integrated collaborate protocols and support to synergize efforts.

Medical teachers' opinions about students with neurodevelopmental disorders and their management

BACKGROUND

Some students have neurodevelopmental disorders that might affect their academic and professional careers if they are not identified and addressed by specific pedagogic adaptations. The objective of this work was to describe medical teachers' opinions of students with neurodevelopmental disorders and their management of these students.

METHODS

An anonymous cross-sectional electronic survey was performed to describe medical teachers' opinions about the impact of neurodevelopmental disorders on the student's life and on the medical teachers' management. aThe survey was created, including visual analogic scales and free text, to assess teachers' opinions from identification and assessment of neurodevelopemental burden on students and teachers, to their own knowledge about neurodevelopemental disorders and the specific pedagogic management available. The survey was sent to 175 medical teachers in 2019, of whom 67 responded. Quantitative descriptive statistics and qualitative analysis of free text were reported.

RESULTS

Many medical teachers report having encountered students who might have had neurodevelopmental disorders (dyspraxia 33%; dyslexia 46%; autism spectrum disorders 68%; attention deficit hyperactivity disorders 75%). Impact on students and on teachers was considered as important (mean VAS score for impact over 60/100 for all syndromes except for dyspraxia). Medical teachers' self-reported knowledge about neurodevelopmental disorders (mean VAS score 43.9/100) and available pedagogical adaptations (mean VAS score 19.0/100) was limited. The teachers were concerned about ethical issues (mean VAS score 72.2/100) but were interested in receiving specialized training (mean VAS score 64.4/100).

CONCLUSION

Medical teachers feel unprepared to manage students with neurodevelopmental disorders. They would be interested in specific training and procedures about the pedagogic management of these students.

Guidelines: The dos, don'ts and don't knows of remediation in medical education

INTRODUCTION

Two developing forces have achieved prominence in medical education: the advent of competency-based assessments and a growing commitment to expand access to medicine for a broader range of learners with a wider array of preparation. Remediation is intended to support all learners to achieve sufficient competence. Therefore, it is timely to provide practical guidelines for remediation in medical education that clarify best practices, practices to avoid, and areas requiring further research, in order to guide work with both individual struggling learners and development of training program policies.

METHODS

Collectively, we generated an initial list of Do's, Don'ts, and Don't Knows for remediation in medical education, which was then iteratively refined through discussions and additional evidence-gathering. The final guidelines were then graded for the strength of the evidence by consensus.

RESULTS

We present 26 guidelines: two groupings of Do's (systems-level interventions and recommendations for individual learners), along with short lists of Don'ts and Don't Knows, and our interpretation of the strength of current evidence for each guideline.

CONCLUSIONS

Remediation is a high-stakes, highly complex process involving learners, faculty, systems, and societal factors. Our synthesis resulted in a list of guidelines that summarize the current state of educational theory and empirical evidence that can improve remediation processes at individual and institutional levels. Important unanswered questions remain; ongoing research can further improve remediation practices to ensure the appropriate support for learners, institutions, and society.

Effects of targeted remediation in anatomy for first year medical students

The aim of this study was to assess the effectiveness of a questionnaire to guide targeted remediation among undergraduate medical students in anatomy. Seventy-five students from a medical college in South India who failed in the first internal theory examination were administered a validated 35-item questionnaire. The total and domain specific questionnaire scores were calculated. Specific weekly interventions for each student based on the questionnaire scores were conducted by appointed academic mentors for three months prior to the second internal examination. The dependent variable was performance in the second internal examination. The students were re-administered the questionnaire after the second internal examination. The independent variables were the marks obtained in the first internal examination, domain specific and total questionnaire scores, sex, and regularity of the student in attending the remedial sessions. Inferential statistical tests used were the chi-square test, independent sample t test, paired t test, multiple regression and binomial logistic regression. Of the 75 students who underwent remediation, 54 (72%) passed in the second internal examination. The scores in the second internal examination among these students was found to be significantly higher as compared to the first internal examination. The total, subject related and study skills questionnaire score were significantly lower after remediation. Students who were irregular had a significantly lower pass rate. The multivariate analysis showed that only the first internal marks added significantly to the prediction about second internal performance. This study provides evidence to show that struggling students perceive a benefit from targeted remediation.

A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity

The relatively new term "Professional Identity Formation" (PIF) complements behavior-based and attitude-based perspectives on professionalism. Unprofessional behavior and its remediation should also be addressed from this perspective. However, a framework is needed to guide discussion and remediation of unprofessional behavior, which can encompass behavior-based, attitude-based, and identity-based perspectives on professionalism. To this end, the authors propose a multi-level professionalism framework which describes, apart from professional behavior, more levels which influence professional performance: environment, competencies, beliefs, values, identity, and mission. The different levels can provide tools for educators to address and discuss unprofessional behavior with their students in a comprehensive way. By reflecting on all the different levels of the framework, educators guard themselves against narrowing the discussion to either professional behavior or professional identity. The multi-level professionalism framework can help educators and students to gain a better understanding of the root of unprofessional behavior, and of remediation strategies that would be appropriate. For despite the recent emphasis on PIF, unprofessional behavior and its remediation will remain important issues in medical education.

Factors Facilitating Academic Success in Dental Students After Initial Failure: A Qualitative Study

Most previous research on academic failure has sought to understand the reasons students failed. The aim of this study was to identify factors that led to academic success for dental students who had previously failed written examinations, using interviews based on Appreciative Inquiry (AI). The AI approach led the investigators to focus on positive aspects of what helped students overcome failure, rather than the reasons for it. Students in this qualitative study, conducted in 2016 at a dental college in India, completed a questionnaire with six open-ended questions and participated in individual semi-structured interviews. Purposive sampling identified 25 students as possible participants; 21 volunteered to participate; and data saturation was reached after interviews with 15. Four key themes were identified in the data collected. On the theme of learning strategies, participants mentioned modifying their attitude toward studying and making it learning-oriented. On the theme of resources, participants reported strategies for obtaining books, others' notes, and teachers' guides to help with studying. In the third theme, psychological aspects, students reported methods used to motivate themselves to succeed after failing. The fourth theme, environmental factors, concerned the key means of support provided by parents, teachers, and seniors/peers. All the students reported that the failure had been a turning point and that overcoming it had boosted their self-confidence. One student said he learned to "never give up and keep trying till you succeed," and most spoke of continuing the best practices they learned. These findings suggest that knowledge-oriented studying, conceptual learning, appropriate study material, internal motivation, and support of parents, teachers, and peers may help dental students overcome failure.

Rethinking Remediation: A Model to Support the Detailed Diagnosis of Clinicians' Performance Problems and the Development of Effective Remediation Plans

The successful remediation of clinicians demonstrating poor performance in the workplace is essential to ensure the provision of safe patient care. Clinicians may develop performance problems for numerous reasons, including health, personal factors, the workplace environment, or outdated knowledge/skills. Performance problems are often complex involving multifactorial issues, encompassing knowledge, skills, and professional behaviors. It is important that (where possible and appropriate) clinicians are supported through effective remediation to return them to safe clinical practice. A review of the literature demonstrated that research into remediation is in its infancy, with little known about the effectiveness of remediation programs currently. Current strategies for the development of remediation programs are mostly "intuitive"; a few draw upon established theories to inform their approach. Similarly, although it has been established that identification of the nature/scope of performance problems through assessment is an essential first step within remediation, the need for a more widespread "diagnosis" of why the problems exist is emerging. These reasons for poor performance, particularly in the context of experienced practicing clinicians, are likely to have an impact on the potential success of remediation and should be considered within the "diagnosis." A new model for diagnosing the performance problems of the clinicians has been developed, using behavioral change theories to explore known barriers to successful remediation, such as insight, motivation, attitude, self-efficacy, and the working environment, in addition to addressing known deficits regarding knowledge and skills. This novel approach is described in this article. An initial feasibility study has demonstrated the acceptability and practical implementation of our model.

Cognitive Style and Mobile E-Learning in Emergent Otorhinolaryngology-Head and Neck Surgery Disorders for Millennial Undergraduate Medical Students: Randomized Controlled Trial

Background

Electronic learning (e-learning) through mobile technology represents a novel way to teach emergent otorhinolaryngology-head and neck surgery (ORL-HNS) disorders to undergraduate medical students. Whether a cognitive style of education combined with learning modules can impact learning outcomes and satisfaction in millennial medical students is unknown.

Objective

The aim of this study was to assess the impact of cognitive styles and learning modules using mobile e-learning on knowledge gain, competence gain, and satisfaction for emergent ORL-HNS disorders.

Methods

This randomized controlled trial included 60 undergraduate medical students who were novices in ORL-HNS at an academic teaching hospital. The cognitive style of the participants was assessed using the group embedded figures test. The students were randomly assigned (1:1) to a novel interactive multimedia (IM) group and conventional Microsoft PowerPoint show (PPS) group matched by age, sex, and cognitive style. The content for the gamified IM module was derived from and corresponded to the textbook-based learning material of the PPS module (video lectures). The participants were unblinded and used fully automated courseware containing the IM or PPS module on a 7-inch tablet for 100 min. Knowledge and competence were assessed using multiple-choice questions and multimedia situation tests, respectively. Each participant also rated their global satisfaction.

Results

All of the participants (median age 23 years, range 22-26 years; 36 males and 24 females) received the intended intervention after randomization. Overall, the participants had significant gains in knowledge (median 50%, interquartile range [IQR]=17%-80%, P<.001) and competence (median 13%, IQR=0%-33%, P=.006). There were no significant differences in knowledge gain (40%, IQR=13%-76% vs 60%, IQR=20%-100%, P=.42) and competence gain (0%, IQR= −21% to 38% vs 25%, IQR=0%-33%, P=.16) between the IM and PPS groups. However, the IM group had a higher satisfaction score (8, IQR=6-9 vs 6, IQR=4-7, P=.01) compared with the PPS group. Using Friedman’s two-way nonparametric analysis of variance, cognitive styles (field-independent, field-intermediate, or field-dependent classification) and learning modules (IM or PPS) had significant effects on both knowledge gain (both adjusted P<.001) and satisfaction (both adjusted P<.001).

Conclusions

Mobile e-learning is an effective modality to improve knowledge of emergent ORL-HNS in millennial undergraduate medical students. Our findings suggest the necessity of developing various modules for undergraduate medical students with different cognitive styles.

Trial Registration

Clinicaltrials.gov NCT02971735; https://clinicaltrials.gov/ct2/show/NCT02971735 (Archived by WebCite at http://www.webcitation.org/6waoOpCEV)

A medical student in private practice for a 1-month clerkship: a qualitative exploration of the challenges for primary care clinical teachers

PURPOSE

The predicted shortage of primary care physicians emphasizes the need to increase the family medicine workforce. Therefore, Swiss universities develop clerkships in primary care physicians' private practices. The objective of this research was to explore the challenges, the stakes, and the difficulties of clinical teachers who supervised final year medical students in their primary care private practice during a 1-month pilot clerkship in Geneva.

METHODS

Data were collected via a focus group using a semistructured interview guide. Participants were asked about their role as a supervisor and their difficulties and positive experiences. The text of the focus group was transcribed and analyzed qualitatively, with a deductive and inductive approach.

RESULTS

The results show the nature of pressures felt by clinical teachers. First, participants experienced the difficulty of having dual roles: the more familiar one of clinician, and the new challenging one of teacher. Second, they felt compelled to fill the gap between the academic context and the private practice context. Clinical teachers were surprised by the extent of the adaptive load, cognitive load, and even the emotional load involved when supervising a trainee in their clinical practice. The context of this rotation demonstrated its utility and its relevance, because it allowed the students to improve their knowledge about the outpatient setting and to develop their professional autonomy and their maturity by taking on more clinical responsibilities.

CONCLUSION

These findings show that future training programs will have to address the needs of clinical teachers as well as bridge the gap between students' academic training and the skills needed for outpatient care. Professionalizing the role of clinical teachers should contribute to reaching these goals.