Trusted to Learn: a Qualitative Study of Clerkship Students' Perspectives on Trust in the Clinical Learning Environment

BACKGROUND

Trust informs supervision decisions in medical training. Factors that influence trust differ depending on learners' and supervisors' level. Research has focused on resident trainees; questions exist about how medical students experience entrustment.

OBJECTIVE

This study examines how clerkship students perceive supervisors' trust in them and its impact on their learning.

DESIGN

Qualitative study using individual semi-structured interviews.

PARTICIPANTS

Clerkship medical students at the University of California, San Francisco.

APPROACH

We invited 30 core clerkship students to participate in interviews (October 2017 to February 2018) eliciting examples of appropriate, over-, and under-trust. We coded and analyzed transcripts using thematic analysis.

KEY RESULTS

Sixteen (53%) students participated. Three major themes arose: trust as scaffolding for learning, effects of trust on the learning environment, and consequences of trust for patients. Appropriate trust usually involved coaching and close guidance, often with more junior supervisors (interns or residents). These situations fostered students' motivation to learn, sense of value on the team, and perceived benefits to patients. Over-trust was characterized by task assignment without clear instruction, supervision, or feedback. Over-trust prompted student anxiety and stress, and concerns for potential patient harm. Under-trust was characterized by lack of clarity about the student role, leading to frustration and discontent, with unclear impact on patients. Students attributed inappropriate trust to contextual and supervisor factors and did not feel empowered to intervene due to concerns about performance evaluations and hierarchy.

CONCLUSIONS

As early learners in the clinical workplace, students frame trust as entailing high levels of support. It is important for medical educators to consider ways to train resident and faculty supervisors to enact trust and supervision for students differently than for residents. Structures that encourage students and supervisors to discuss trust and supervision in a transparent way can enhance learning.

Electronic Health Record Use in Internal Medicine Clerkships and Sub-internships for Medical Students Graduating from 2012 to 2016

BACKGROUND

As electronic health records (EHRs) became broadly available in medical practice, effective use of EHRs by medical students emerged as an essential aspect of medical education. While new federal clinical documentation guidelines have the potential to encourage greater medical student EHR use and enhance student learning experiences with respect to EHRs, little is known nationally about how students have engaged with EHRs in the past.

OBJECTIVE

This study examines medical student accounts of EHR use during their internal medicine (IM) clerkships and sub-internships during a 5-year time period prior to the new clinical documentation guidelines.

DESIGN

An online survey about EHR use was administered to medical students immediately after they completed USMLE Step 2 CK.

PARTICIPANTS

The sample included 16,602 medical students planning to graduate from US medical schools from 2012 to 2016.

MAIN MEASURES

Descriptive statistics were computed to determine the average percentage of students engaged in various health record activities during their IM educational experiences by graduation year.

KEY RESULTS

The vast majority (99%) of medical students used EHRs during IM clerkships or sub-internships. Most students reported that they entered information into EHRs during the inpatient component of the IM clerkship (84%), outpatient component of the IM clerkship (70%), and the IM sub-internship (92%). Yet, 43% of the students who graduated in 2016 never entered admission orders and 35% of them never entered post-admission orders.

CONCLUSIONS

Medical school graduates ought to be able to effectively document clinical encounters and enter orders into EHR systems. Although most students used and entered information into EHRs during their IM clinical training, many students appear to have received inadequate opportunities to enter notes or orders, in particular. Implications for graduate medical education preparedness are considered. Future research should address similar questions using comparable national data collected after the recent guideline changes.

Clerkship Grading Committees: the Impact of Group Decision-Making for Clerkship Grading

BACKGROUND

Faculty and students debate the fairness and accuracy of medical student clerkship grades. Group decision-making is a potential strategy to improve grading.

OBJECTIVE

To explore how one school's grading committee members integrate assessment data to inform grade decisions and to identify the committees' benefits and challenges.

DESIGN

This qualitative study used semi-structured interviews with grading committee chairs and members conducted between November 2017 and March 2018.

PARTICIPANTS

Participants included the eight core clerkship directors, who chaired their grading committees. We randomly selected other committee members to invite, for a maximum of three interviews per clerkship.

APPROACH

Interviews were recorded, transcribed, and analyzed using inductive content analysis.

KEY RESULTS

We interviewed 17 committee members. Within and across specialties, committee members had distinct approaches to prioritizing and synthesizing assessment data. Participants expressed concerns about the quality of assessments, necessitating careful scrutiny of language, assessor identity, and other contextual factors. Committee members were concerned about how unconscious bias might impact assessors, but they felt minimally impacted at the committee level. When committee members knew students personally, they felt tension about how to use the information appropriately. Participants described high agreement within their committees; debate was more common when site directors reviewed students' files from other sites prior to meeting. Participants reported multiple committee benefits including faculty development and fulfillment, as well as improved grading consistency, fairness, and transparency. Groupthink and a passive approach to bias emerged as the two main threats to optimal group decision-making.

CONCLUSIONS

Grading committee members view their practices as advantageous over individual grading, but they feel limited in their ability to address grading fairness and accuracy. Recommendations and support may help committees broaden their scope to address these aspirations.

Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career: A Systematic Review

BACKGROUND

Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context.

METHODS

We searched MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, The Cochrane Library, and Dissertations & Theses A&I for articles published between 1993 and February 20, 2015. We included quantitative and qualitative studies reporting on primary care specialty choice outcomes of interventions in the undergraduate medical curriculum, without geographic restrictions. Data extracted included study characteristics, intervention details, and relevant outcomes. Studies were assessed for quality and strength of findings using a five-point scale.

RESULTS

The review included 72 articles reporting on 66 different interventions. Longitudinal programs were the only intervention consistently associated with an increased proportion of students choosing primary care. Successful interventions were characterized by diverse teaching formats, student selection, and good-quality teaching. Study quality had not improved since recommendations were published in 1995. Many studies used cross-sectional designs and non-validated surveys, did not include control groups, and were not based on a theory or conceptual framework.

DISCUSSION

Our review supports the value of longitudinal, multifaceted, primary care programs to increase the proportion of students choosing primary care specialties. Isolated modules or clerkships did not appear to be effective. Our results are in line with the conclusions from previous reviews and add an international perspective, but the evidence is limited by the overall low methodological quality of the included studies. Future research should use more rigorous evaluation methods and include long-term outcomes.

A model for interprofessional health disparities education: student-led curriculum on chronic hepatitis B infection

BACKGROUND

Although health disparities are commonly addressed in preclinical didactic curricula, direct patient care activities with affected communities are more limited.

PURPOSE

To address this problem, health professional students designed a preclinical service-learning curriculum on hepatitis B viral (HBV) infection, a major health disparity affecting the Asian/Pacific Islander (API) population, integrating lectures, skills training, and direct patient care at student-run clinics.

SETTING

An urban health professions campus.

METHODS

Medical and other health professional students at University of California, San Francisco, organized a preclinical didactic and experiential elective, and established two monthly clinics offering HBV screening, vaccination, and education to the community.

RESULTS

Between 2004 and 2009, 477 students enrolled in the student-led HBV curriculum. Since the clinics' inception in 2007, 804 patients have been screened for chronic HBV; 87% were API immigrants, 63% had limited English proficiency, and 46% were uninsured. Serologically, 10% were found to be chronic HBV carriers, 44% were susceptible to HBV, and 46% were immune.

DISCUSSION

Our student-led didactic and experiential elective can serve as an interprofessional curricular model for learning about specific health disparities while providing important services to the local community.

Medical students' perceptions of their teachers' and their own cultural competency: implications for education

BACKGROUND

Enhancing the cultural competency of students is emerging as a key issue in medical education; however, students may perceive that they are more able to function within cross-cultural situations than their teachers, reducing the effectiveness of cultural competency educational efforts.

OBJECTIVE

The purpose of our study was to compare medical students' perceptions of their residents, attendings, and their own cultural competency.

DESIGN

Cross-sectional study.

MAIN MEASURES

A questionnaire containing previously validated instruments was administered to end-of-third-year medical students at four institutions throughout the US. Repeated measures multivariate analysis was used to determine differences in student ratings.

PARTICIPANTS

Three hundred fifty-eight medical students from four schools participated, for an overall response rate of 65%.

RESULTS

Analysis indicated overall statistically significant differences in students' ratings (p < 0.001, eta(2) = 0.33). Students rated their own cultural competency as statistically significantly higher than their residents, but similar to their attendings. For reference, students rated the patient care competency of themselves, their residents, and their attendings; they rated their attendings' skills as statistically significantly higher than residents, and residents as statistically significantly higher than themselves. There were differences between cultural competency and patient care ratings.

CONCLUSIONS

Our results indicate that students perceive the cultural competency of their attendings and residents to be the same or lower than themselves. These findings indicate that this is an important area for future research and curricular reform, considering the vital role that attendings and residents play in the education of medical students.

Long-term retention of smoking cessation counseling skills learned in the first year of medical school

BACKGROUND

Tobacco use is a significant cause of preventable morbidity and mortality in the United States, yet clinicians underutilize smoking cessation counseling. Medical schools are increasingly including training for smoking cessation skills in preclinical curricula. Information about long-term retention of these skills is needed.

OBJECTIVE

To assess retention of smoking cessation counseling skills learned in the first year of medical school.

DESIGN

Retrospective review of data collected for routine student and curriculum assessment.

PARTICIPANTS

Two cohorts of medical students at the University of Connecticut School of Medicine (total N = 112) in 1999-2001 and 2002-2004.

MEASUREMENTS AND MAIN RESULTS

Scores by standardized patients were compared from first and fourth-year assessments, based on checklist items corresponding to the 5 strategies recommended by the U.S. Public Health Service (Ask, Advise, Assess, Assist, Arrange). In study cases, 97% of first-year students "asked" about smoking and retained this skill in fourth year (p = .08). Ninety-four percent of first-year students "assessed" readiness to quit and retained this skill (p = .21). Ninety-six percent of first-year students "advised" smokers to quit and retained this skill (p = .18). Eighty-six percent of first year students "assisted" smokers in quitting and retained this skill (p = 0.10). Eighty-one percent of first year students "arranged" follow-up contact and performance of this strategy improved in the fourth year to 91% (p = .03).

CONCLUSIONS

Smoking cessation counseling skills demonstrated by first year medical students were, with brief formal reinforcement in the third year, well retained into the fourth year of medical school. It is appropriate to begin this training early in medical education.