Assessment
The Unusual Complexity and Inverted Association of Medical Student Perseverance and Their Values
Robert Treat
Medical College of Wisconsin
PURPOSE: Medical students are amazingly resilient in the face of academic challenges, studying relentlessly enormous volumes of course materials, and having scant time for personal endeavors. Perseverance is a major element of resilience that requires persistence in pursuing something despite the difficulty in achieving success. Resilient individuals must therefore value the outcomes they strive to achieve. The purpose of this study is to analyze the relationship of medical student perseverance and values as impacted by gender.
METHODS: In 2017/18, 205 of 500 M-1/M-2 medical students (106 males/99 females) voluntarily completed these self-reported surveys: RS-25 Resilience Scale and Human Values Inventory. Inter-item reliability determined with Cronbach’s alpha. Pearson correlations (r) and stepwise multivariate linear regressions used for predicting perseverance scores from ten value domains and 56 facets. IBM SPSS 24.0 generated statistical analysis. This research approved by institution’s IRB.
RESULTS: Perseverance (alpha=0.7) scores were significantly (p<.050) and negatively correlated to all ten human value domains: universalism (r= -0.5), benevolence (-0.4), conformity (-0.3), tradition (-0.3), security (-0.4), power (-0.4), achievement (-0.4), hedonism (-0.3), stimulation (-0.3), and self-direction (-0.4). The remaining four factors of resilience (authenticity, equanimity, purpose, self-reliance) had positive correlations with the ten values. Linear regression results for male perseverance (R=0.43, p<.001) was predicted by four values facets: excitement (beta=0.3), obedience (0.3), wisdom (-0.4), and safety (-0.5). Linear regression results for female perseverance (R=0.54, p<.001) was predicted by creativity (0.5), self-discipline (0.3), meaning in life (-0.3), broad-mindedness (-0.3), enjoyment (-0.3), and wisdom (-0.4).
CONCLUSIONS: Medical student perseverance increased as their self-enhancement values such as hedonism and power decreased, but also as their self-transcendent values such as benevolence did. Predictive modelling revealed greater complexity as resilient female students valued creativity and self-discipline and male students valued excitement, but both devalued wisdom while persisting towards goals. Values must be prioritized when in conflict.
Curriculum
Pharmacology as a continuum: a curricular model for spaced repetition, vertical and horizontal integration
Jennifer Cleveland
Virginia Tech Carilion School of Medicine
PURPOSE: The pharmacology content at Virginia Tech Carilion School of Medicine is horizontally integrated across several curricular elements. Historically, large group sessions focused on organ-based pharmacology, whereas Problem-based Learning (PBL) included all pharmacology presented in the featured case. This approach rapidly exposed students to numerous pharmacological agents, but the student-led PBL forum proved to be diffuse and frustrating as cases often included incidental drugs, not directly related to the pathological focus. Despite efforts to reinforce content in several curricular locations, data from the AAMC graduate questionnaire and student performance on end of block NBME exams indicated a need to reevaluate the delivery.
METHODS: We implemented a new curricular strategy to better coordinate pharmacology delivery across Basic Science and PBL. In each PBL case, we identified the drugs related to the content being presented in large group sessions and wrote specific objectives to highlight key aspects of the drug. Additionally, as students’ progress through the M1 and M2 years, drugs that had been addressed in previous cases were highlighted as a reminder to the students to review the content.
RESULTS: Student performance on pharmacology content on Block NBME exams has improved dramatically. (Block I up 5 points, Block II up 11 points and Block III 5 points when compared to exam performance metrics AY 16 -17).
CONCLUSIONS: The restructure of pharmacology across curricular elements allowed both students and faculty to focus on important aspects of a specific drug, reducing the stress and often extraneous nature of exploring all drugs in a PBL case. This modification has positively increased student performance and perception of pharmacology delivery. Integrated curricular design requires elegant coordination across elements and in this case, we have been successful in focusing the student learning on relevant content and enhanced overall performance.
Curriculum
IMPROVING STUDENT TEAMWORK IN THE PRECLINICAL CURRICULUM
Henrike Besche
Harvard Medical School
PURPOSE: Recently we changed our preclinical curriculum to case-based collaborative learning (CBCL). In CBCL students apply what they learn at home to a new case in class. Classroom discussions alternate between students working in small teams and group discussions. Classes are designed to foster critical thinking and students find CBCL classes stimulating and engaging. However, students reported problems in working as a team. Based on this feedback we set out to: 1) Understand the experiences student were having; 2) Test an intervention to see if team dynamics could be improved.
METHODS: A validated team performance scale was combined with two-open-ended questions. This survey was administered to all teams in the course at several time points, including before and after an intervention. Mixed methods were used to categorize team effectiveness and identify common characteristics.
RESULTS: Without intervention about half of the teams showed signs of dysfunction. The most successful teams had a process in place in how they went about their work and succeeded at creating a safe learning environment. When given a structured activity to set team norms, team function improved significantly. Importantly, both dysfunctional teams and teams that reported great interpersonal relationships struggled with creating respectful discourse.
CONCLUSIONS: Interpersonal and communication skills are essential to the medical profession and traditionally taught in context of clinical care. The CBCL curriculum provides rich opportunities for students to hone interpersonal and teamwork skills in the preclinical curriculum if given appropriate resources. Supporting students in creating psychologically safe teams and raising awareness on “group think” is essential for students to form effective teams and engage higher order critical thinking.
Curriculum
Facing uncertainty in the GME learning environment: perceptions and experiences of internal medicine residents and attending physicians at a US academic medical center
Galina Gheihman
Harvard Medical School
PURPOSE: Clinical uncertainty is pervasive in medicine, yet many clinicians are uncomfortable with uncertainty and unwilling to acknowledge it. Studies link intolerance of uncertainty to burnout, ineffective communication strategies, cognitive biases, and inappropriate resource use. Little is known about how uncertainty manifests in the clinical setting and the perceptions of physicians and trainees facing uncertainty. Understanding clinicians’ experiences may help improve how physicians and patients acknowledge, manage, and cope with uncertainty, as well as identify educational strategies for promoting tolerance of uncertainty among trainees.
METHODS: This mixed-methods study investigated perceptions and experiences of uncertainty in the clinical environment among internal medicine residents and attending physicians at a single US academic medical center. A survey, semi-structured interviews, and in-person observations were conducted.
RESULTS: Regression analysis of validated survey instruments assessing stress, burnout, and tolerance of uncertainty demonstrated resident physicians (n=35) have more perceived stress from uncertainty than attending physicians (n=14) (15.6 [5.0] vs. 19.0 [3.6], p<0.05), and significantly higher symptoms of burnout (7.1 [2.9] vs. 4.9 [2.0], p<0.05). Perceiving the learning environment as more competitive and/or stressful strongly correlates with an increased reluctance to disclose uncertainty (r= -0.44, p<0.01). Qualitative analysis revealed four themes: (1) a desire to communicate uncertainty to patients; (2) the influence of authority; (3) role modeling to promote tolerance of uncertainty; and (4) embracing uncertainty is not part of formal medical curricula.
CONCLUSIONS: Uncertainty is inherent to medicine; yet strategies to tolerate and manage uncertainty in the clinical setting and teach residents such skills are lacking. We found that level of training and role impacts how uncertainty is emotionally perceived and its impact on stress and burnout. Attending physicians can play an important educational role by modeling explicit language and management strategies for uncertainty in clinical encounters. Medical curricula should include formal strategies to acknowledge, embrace, and manage clinical uncertainty.
Instructional Methods
Effectiveness of Small Group Discussions (SGD) in Pharmacology Course at Avalon University School of Medicine
Sireesha Bala Arja
Avalon University School of Medicine
Purpose: Small group discussions (SGD) are used in medical education to foster self-directed learning (SDL), communication skills, and professionalism. Small group discussions can involve a variety of tasks such as critical thinking, problem-solving, and brainstorming. The objective of this study is to find out if SGD can improve the students’ learning and their performance in assessments than individual SDL and lectures.
Methods: This is a quasi-experimental study to investigate if SDL in groups (SGD) is better than individual SDL and lectures. Students were required to watch videos and do the self-directed learning before coming to lecture. Students attended the lecture for fifty minutes. At this point, students were assessed by a pre-test. After the test, students were involved in SGD. A post-test was given after the SGD. The data were collected for six topics in Pharmacology course. At the end of the course, students received an evaluation containing quantitative questions and open-ended questions to gather feedback.
Results: The students’ performance was compared between pre-test and post-test for six topics, and significant improvement was demonstrated in five topics (paired t-test, p<0.05). Student performance on the topics which were taught using SGD was compared with overall performance on pharmacology final exam, demonstrated a significant difference (paired t-test, p=0.031). Students’ overall performance in Pharmacology with SGD was also improved compared to the overall performance of the previous class of students who didn’t have SGD (unpaired t-test, p=0.025). Finally, the questions on the Likert scale were analyzed for descriptive statistics, including mean, median, and mode. Student responses to the SGD were satisfactory.
Conclusion The small group discussions for the Pharmacology course improved students’ learning and their performance in assessments at Avalon University School of Medicine. As the sample size is small, we plan to continue evaluating SGDs with larger sample size in future.
Instructional Methods
Changing the medical narrative: incorporation of illness stories into gross anatomy
Carrie Elzie
Eastern Virginia Medical School
PURPOSE
Narrative medicine is an important and expanding new field that recognizes the value of storytelling. It involves recognizing, absorbing, metabolizing, interpreting and being moved by the stories of illness. This valuable aspect of medicine was introduced into a medical gross anatomy course by transforming the illness stories of a living anatomical donor into interactive cases and discussions to complement the basic science and provide early patient exposure.
METHODS The illness stories and medical records of a living anatomical donor were collected and used to create interactive cases to teach anatomy. Each case allowed the students to delve into the patient’s perspective while learning the underlying basic science and clinical principles. A follow-up session provided the students with the opportunity for personal connection and a forum to ask questions with the patient. Students’ reflections on the principle takeaways were collected. Exam questions and knowledge retention were analyzed compared to other case modalities. Qualitative feedback was collected from focus groups and course evaluations.
RESULTS One hundred fifty students completed five cases with Mr. Clark. Thematic analysis of the students’ responses revealed two of the top three take-aways from each case were consistently humanistic rather than scientific/clinical with a focus on the patient’s feelings, reactions and lifestyle. Performance on exams was similar to content taught in other modalities. Retention rates of patients’ diagnoses were 50% higher for cases that contained personal narratives. Feedback was overwhelmingly positive with an appreciation for the humanistic elements of this teaching modality.
CONCLUSIONS: Changing the curriculum to include illness stories has shifted the medical narrative toward a more compassionate and humanized conversation without sacrificing medical knowledge. The addition of illness narratives has the potential to foster interpersonal development in affective, cognitive, and experiential domains thereby positively shaping the hidden curriculum into a more humanistic and empathetic message.
Instructional Methods
Examining strategies to promote cognitive integration of basic and clinical sciences in novice learners
Kristina Lisk
Humber College
Purpose: The importance of integrated basic and clinical science knowledge is well recognized; however, supporting the development of learners’ integrated knowledge continues to be an educational challenge. Previous work suggests that learning strategies, such as self-explanation, might promote and support the development of cognitive integration. In this study, we examined the relative impact of two basic science instructional approaches (integrated and segregated instruction) and a learning strategy (self-explanation) on novices’ diagnostic accuracy.
Methods: Allied health students (N=71) were taught the clinical features of four musculoskeletal pathologies. Students randomly assigned to the integrated group were presented with descriptions that explicitly integrated the clinical features with basic science mechanisms. The segregated group were taught the basic science mechanisms and clinical features separately. The self-explanation group received the same learning materials as the integrated group, but were also prompted to engage in a self-explanation task immediately after learning each pathology. The self-explanation task required that they articulate why certain clinical features arose. All participants completed a diagnostic accuracy and memory test immediately after learning and 1-week later.
Results: The integrated group outperformed the self-explanation and segregated learning groups on the diagnostic accuracy and memory test. Diagnostic accuracy declined across all three groups after 1-week and the largest drop in performance was observed in the self-explanation group.
Conclusion: Explicitly integrating basic and clinical science instruction positively impacts novices’ diagnostic performance and ability to recall clinical features associated with different pathologies. However, generating self-explanations while learning with integrated basic science materials did not enhance novices’ diagnostic performance. We hypothesize that the structure of the self-explanation task may not have supported the development of a holistic understanding of each disease. These findings highlight the importance of carefully considering how learning strategies are structured and applied in order to optimize learning of the basic and clinical sciences.
Instructional Methods
Using Peer Evaluation to Promote Student Understanding and Satisfaction during Team-Based Learning Exercises
David Swope
Cooper Medical School of Rowan University
PURPOSE: While initially recognized as an essential element in team-based learning (TBL) exercises, peer review is often omitted in biomedical TBL design due to minimal and often contradictory supportive evidence. The objective of this study is to evaluate the impact of peer evaluation on student performance, participation and group dynamic during TBL sessions within a summer enrichment program at Cooper Medical School of Rowan University (CMSRU).
METHODS: Students enrolled in the CMSRU summer enrichment program participated in 3 TBL exercises within a traditional 6-week Biochemistry section. TBL teams of 5-6 students were established randomly and remained consistent throughout the program. Group dynamic was evaluated via audio recording and an anonymous survey (27 question, Likert scale). 3 cohorts of students were evaluated in the study: a control group (n=31); a group (n=34) exposed to graded peer review (25% of TBL) that required self-assessment and evaluation of group members on preparation, participation, teamwork, professionalism and overall production; and a group (n=30) subject to ungraded peer assessment (0% of TBL) using the aforementioned peer review tool.
RESULTS: Addition of ungraded peer evaluation TBL incentive structure resulted in a significant increase in average iRAT scores compared to either no peer evaluation or graded peer evaluation. Moreover, student satisfaction and group dynamic, as assessed on an anonymous survey, were maintained with the inclusion of peer evaluation. Results also indicated a positive correlation between iRAT performance and self/peer reviews advocating the accuracy of the peer assessment mechanism.
CONCLUSIONS: Evidence-based evaluation of TBL design and implementation of innovative modifications is necessary for advancements in medical pedagogy. Preliminary evidence suggests that inclusion of ungraded peer review results in improved TBL performance and preserves student satisfaction. Continued appraisal of the positive outcomes of peer evaluation will help shape future student-centered learning practices.
Technology and Innovation
A NOVEL APPROACH FOR THE INTEGRATION AND APPLICATION OF MEDICAL BIOCHEMISTRY IN THE MEDICAL SCHOOL CURRICULUM VIA POWERAPPS APPLICATIONS
Paul Chastain II
University of Illinois, College of Medicine at Chicago, Rockford Campus
PURPOSE: We have developed an App that allows students (either alone or in teams; self-guided or guided) to go on biochemical adventures that enable them to integrate their medical and biochemical knowledge with their clinical skills.
METHODS: Each adventure starts with a brief overview of the pathway of interest as well as links to relevant resources that allows them to have all the information they need in hand. Students are told an enzyme in this pathway is dysfunctional and the students have to use their biochemical and medical knowledge to predict how elements within various health status panels change in a person with this disorder. Next, the students have to decide how a person would present as a consequence of this metabolic defect. After they press submit, the answer along with a corresponding explanation is revealed to them. Finally, students are given a series of clinical presentations associated with defects in various pathways, and the teams have to determine which pathway/enzyme is defective and to defend how information within the vignette supports their answer. After entering the evidence, the team presses submit, and the answer along with a corresponding explanation is revealed to them.
RESULTS: Around 70% of the students rated the PowerApp adventures as excellent or good use of their time (the remainder thought it was a fair use of their time).
CONCLUSION: We have found that students tend to use the App in groups and like to go on biochemistry adventures together. While most feedback has been extremely positive, most students would like even more clinical vignette examples. The value of the App modules/format is that students can continue using the App after class as a study aid. The App is easy to develop, alter, and share.
Student Support
STUDY STRATEGY INTERVIEWS SUGGEST OVERWHELMED AND OVER-RELIANT ATTITUDES IN FIRST-YEAR INDIANA UNIVERSITY MEDICAL STUDENTS
Amberly Reynolds
Indiana University
PURPOSE: First-year medical students are inundated with resources for courses, both required and recommended. Additionally, each course often has lecture slides and/or notes provided. With a multitude of resources, students are expected to define their study strategies to reach successful outcomes, but how do they go about that and what are their attitudes toward that expectation? This research utilizes qualitative methods to analyze first year medical student interviews about their study strategies and the rationale behind them.
METHODS: First-year medical students across all nine Indiana University School of Medicine (IUSM) campuses from 2016 and 2017 cohorts were interviewed (n=58) regarding their study strategies for the Gross Human Anatomy course. Semi-structured interviews were completed over the phone during the summer following the first year and generally lasted between twenty and sixty minutes. Interview questions focused on how students studied for both the lecture and lab components and what influenced their study strategy decisions. Thematic analysis of transcribed interviews pinpointed patterns regarding content resources, study habits and student attitudes toward resources.
RESULTS: Thematic analysis revealed students’ overwhelmed attitude with the number of resources provided but a lack of guidance on how to use said resources. A second theme denotes an over-reliance on professor presentation slides. Comparative analysis between the two cohorts demonstrate differences in organizational strategies of both instructor and student regarding use of resources.
CONCLUSIONS: Medical education faces curricular changes as we work to provide future physicians with the proper content but also important is our ability to teach them the necessary skills of how to use the vast content resources. Particularly pertinent to Anatomy educators is the need to instruct students how to choose and effectively use the multitude of resources. Instructors also need to ensure that students do not believe instructor slideshows contain the only important course content.
Student Support
PREDICTORS OF IMPOSTOR SYNDROME IN MEDICAL STUDENTS AT THE PRECLINICAL-CLINICAL TRANSITION
Beth Levant
University of Kansas Medical Center
PURPOSE: Impostor syndrome, a phenomenon in which individuals distrust their abilities and accomplishments, is a contributor to medical student burnout and an impediment to identity formation as physicians, and can be most pronounced during periods of career transition. Accordingly, this study examined the incidence and severity of impostor syndrome in third-year medical students as they transitioned from the preclinical to clinical phases of their training.
METHODS: A voluntary, anonymous, 60-item survey was administered to third-year medical students at the University of Kansas School of Medicine in October-November of the 2018 fall semester. The survey included the Clance Impostor Phenomenon (IP) Scale, the Perceived Stress (PS) Scale, and demographic characteristics.
RESULTS: A total of 127 of 215 (59%) students surveyed responded with N=111 completing the entire survey. Respondents were 83% Caucasian and 25.8±3 years old (range 23-44). The mean IP score was 63.0±14.6 (moderate-to-frequent impostor feelings) with 42.2% reporting moderate IP feelings, 37.8% frequent IP feelings, and 14.4% intense IP feelings. Females (N=63) had higher IP (p<0.05) and PS (p<0.01) scores than males (N=47). Females also had lower USMLE Step 1 scores (p<0.01). Regression modeling identified USMLE Step 1 score as a driving feature for IP, which was strongly independently correlated with PS. Gender and age also independently predicted PS in controlled analyses.
CONCLUSION: The association of lower USMLE Step 1 scores with impostorism suggests that students’ negative appraisal of their USMLE Step 1 performance can undermine self-confidence, which may adversely affect wellness and, in turn, contribute to burnout and impede identity formation as physicians. This finding may guide the development of interventions to help students negotiate the transition from the preclinical to clinical phases of their training. Supported by the University of Kansas School of Medicine Academy of Medical Educators and NIH CTSA Award UL1TR002366.
Other
TEACHING SQUARES: AN INNOVATIVE APPROACH FOR DEVELOPING PEDAGOGICAL PRACTICES OF MEDICAL FACULTY
Samantha M. Lemus-Martinez
Florida International University, Herbert Wertheim College of Medicine
PURPOSE: FIU Herbert Wertheim College of Medicine is a newer medical school with limited faculty development personnel and no formal/informal process for peer observation of teaching. We piloted “teaching squares” to initiate opportunities for faculty to observe their peers with a focus on pedagogical practices.
METHODS: Teaching squares are groups of 4 cross-disciplinary faculty who observe each other using multiple pedagogical approaches over 2-3 weeks. They are informal, flexible and require limited personnel for oversight. The process begins with a pre-meeting, followed by peer observation, and concludes with feedback and debriefing. The purpose is not to criticize but rather to identify effective pedagogical approaches that might be incorporated in one’s own classes. Feedback meetings are roundtable discussions of strategies individually observed by square members, leading to self-reflection regarding personal problems of practice for which strategies are provided. Debriefing with the faculty developer consists of creating individualized action plans with self-identified areas for growth and provides for personalized support to ensure successful implementation.
RESULTS: Peer observations resulted in the identification of effective pedagogical strategies employed by the faculty, and fostered their implementation in other classroom settings. Significant camaraderie developed among participants resulting in a community of practice where faculty feel comfortable re-engaging with the square to present new pedagogical challenges. Because of its informal, non-threatening nature, members felt free to offer comments and encouragement to others. Those receiving feedback reported that the teaching square format promoted self-reflection on teaching practices and resulted in improvements to their own pedagogy.
CONCLUSION: Participants enjoyed seeing the content and pedagogical expertise of their colleagues and were motivated to make changes to their own teaching practice. The teaching square built faculty development capacity, spreading effective and innovative teaching strategies throughout the medical school.