MEDICAL SCIENCE EDUCATOR.pdf

MedicalScienceEducatorThe Journal of the International

Association of Medical Science Educators

Volume 23 * Issue 2 * 2013ISSN 2156-8650

In this issue:Research-Tutored LearningChallenging Medical Students to Confront their BiasesCultural Competency in the Medical Genetics ClassroomAn e-Learning Intervention to Enhance Medical Student’s CompetenceThe Introduction of Nutrition Education into the Medical School Curriculum

Medical Science Educator The Journal of the International Association

of Medical Science Educators

Editor-in-Chief Peter G.M. de Jong, PhD, NETHERLANDS

Editorial Board David L. Bolender, PhD, USA Sandy Cook, PhD, SINGAPORE John R. Cotter, PhD, USA Sonia J. Crandall, PhD, USA Floyd C. Knoop, PhD, USA Jan B.M. Kuks, MD PhD, NETHERLANDS H. Wayne Lambert, PhD, USA William E. Seifert, PhD, USA Darshana Shah, PhD, USA

Advisory Board Ronald M. Harden, MD, UK Stewart P. Mennin, PhD, BRAZIL Geoff R. Norman, PhD, CANADA

Previous Editors-in-Chief Roger W. Koment, PhD, Founding Editor J. Charles Eldridge, PhD, USA Doug Gould, PhD, USA Uldis N. Streips, PhD, USA

Editorial Assistant Amoritia L. Strogen (JulNet Solutions), USA

Editorial Correspondence Authors can submit their manuscript by email to [email protected].

Instructions for Authors See the last page of this issue and also the Journal’s website for detailed instructions for submissions.

Production JulNet Solutions, LLC, USA

Mission Medical Science Educator is the successor of the journal JIAMSE. It is the peer reviewed publication of the International Association of Medical Science Educators (IAMSE). The journal offers all who teach in healthcare the most current information to succeed in their task by publishing scholarly activities, opinions, and resources in medical science education. Published articles focus on teaching the sciences fundamental to modern medicine and health, and include basic science education, clinical teaching, and the use of modern education technologies. The journal provides the readership a better understanding of teaching and learning techniques in order to advance medical science education.

Indexing The journal is indexed in Ulrichsweb.

Information for Subscribers Medical Science Educator is published online only, in four issues per year, excluding supplements. Issues older than one year after publication will be accessible to all. Access to the most recent issues of the journal is included in the membership fee of IAMSE. Non-members can buy an individual subscription for US$ 149 per year. Medical Libraries can buy a special library subscription to the journal. For more information, see the journal’s website.

All content in Medicine Science Educator reflects the views of the author(s) and does not reflect the official policy of IAMSE unless clearly specified.

ISSN: 2156-8650

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Medical Science Educator © IAMSE 2013 Volume 23(2)

MEDICAL SCIENCE EDUCATOR

The Journal of the International Association of Medical Science Educators

Contents

Letter from the Editor-in-Chief 195 Short Communications Incorporation of “Human Body Composition” Course in the Medical or Premedical Curriculum

196

Yehia M.A-H. Marreez Mapping of Medical Microbiology Content in a Clinical Presentation Curriculum 201 Robin K. Pettit & Yen-Ping Kuo The Effect of a Graduate-Level Course on Health Care for the Urban Underserved on Student Knowledge, Attitudes, and Perceptions

212

Casey M. Rebholz, Lydia A. Bazzano & Benjamin Springgate Original Research Challenging Medical Students to Confront their Biases: A Case Study Simulation Approach

217

Lon J. Van Winkle, Sophie La Salle, Lendell Richardson, Bryan C. Bjork, Paulette Burdick, Nalini Chandar, Jacalyn M. Green, Sean M. Lynch, Chester Robson & Susan M. Viselli

The Introduction of Nutrition Education into the Medical School Curriculum: Using an Elective Course to Teach Students the Fundamentals, the Science, and the Clinical Implications of Food

225

Nupur Agrawal, Sara A. Ostrosky & David Henzi Cultural Competency in the Medical Genetics Classroom: A Case Study for a Diverse Learning Community

233

Shoumita Dasgupta Can PBL Group Assignment Affect Examination Performance? 244 Edward C. Klatt & Tina L. Thompson Pediatric Examinations Content Validity Comparison: In-House Versus NBME Examination

250

Hassib Narchi Racial-Ethnic Differences in Medical Students’ Experiences of Professionalism: A Mixed-Methods Study

259

Lavjay Butani, Ana-Maria Iosif, Alyn Kelley, Omar Washington & Andreea L. Seritan Research-Tutored Learning: An Effective Way for Students to Benefit Research by Critical Appraisal

269

Vincent T. Janmaat, Kim E. Kortekaas, Thomas M. Moerland, Mayke W.C. Vereijken, Jan W. Schoones, Astrid van Hylckama Vlieg & Friedo W. Dekker


An e-Learning Intervention to Enhance Medical Student’s Competence in Oxygen Delivery Methods

278

Shana Godfred-Cato, Michael Metts, Greg Kolbinger, Edward P. Finnerty & Kyla Carney Monograph Teacher Training for Students and Faculty in a Medical School Environment 284 Michael S. Risley Commentary An Institutional Approach to Medical Curriculum Reform: Leadership, Hierarchy and Rigidity as Impediments to Change

290

Karen Malone & Salinder Supri Meeting Report A Learning Community of Learning Communities 293 Interprofessional Education in the Health Sciences 299 Promises and Challenges of Virtual Learning Environment 303 Announcements 306

Medical Science Educator © IAMSE 2013 Volume 23(2) 195


The Journal of the International Association of Medical Science Educators Med Sci Educ 2013; 23(2): 195

Letter from the Editor-in-Chief

Peter G.M. de Jong Leiden University Medical Center, Leiden, The Netherlands

Welcome to the 23(2) issue of Medical Science Educator. This is already the third issue of the year, containing 13 interesting submissions in total. I am very happy that so many authors keep using our journal as a platform to share their scholarly experiences. We present to you eight pieces of original research work, five other articles and three meeting reports. The meeting reports in this issue cover the LCI meeting and two IAMSE Webcast Audio Seminar series, for those who were not able to attend. I truly hope that you as a regular reader will continue to support the journal, either through membership in IAMSE or by an individual subscription. But above all, that you and your colleagues will continue publishing your own scholarly work in our journal for the benefit of all our readers. Enjoy this issue of Medical Science Educator! Peter G.M. de Jong, PhD Editor-in-Chief



The Journal of the International Association of Medical Science Educators Med Sci Educ 2013; 23(2): 196-200

SHORT COMMUNICATIONS

Incorporation of “Human Body Composition” Course in the Medical or Premedical Curriculum

Yehia M.A-H. Marreez Touro University Nevada, Henderson, NV, USA

Abstract Body composition science is concerned with tracking changes in the body component proportions. Body fat, fat-free, and lean masses undergo significant changes in chronic, metabolic, cardiovascular, cancerous disorders and others. Quantitative studies of these changes can be performed with simple, non-invasive, and inexpensive methods. The collected data could have significant clinical values in the prediction, diagnosis, and prognosis of multiple serious diseases particularly those encumbering the healthcare system. However, there is inadequate attention to this field in the medical curricula. We suggest in this article a specific course of “clinical body composition” as an elective for the medical students and/or an essential part of the pre-medical curriculum.

Overview Human body composition is the science that deals with the proportion of the three main body components; fat, muscle, and bone of the human body and usually expressed as percentage of fat mass (FM), fat-free mass (FFM), and percentage of lean body mass (LBM). Body composition changes of an individual may reflect early observable and clinically meaningful physical signs of health status. A strong correlation exists between body composition parameters and risk of occurrence of many disorders such as hypertension, diabetes, hyperlipidemia, coronary heart disease, and heart failure.1 Also, body composition modifications are found to be key factors in evaluating chemotherapy treatment and toxicity as well as survival and quality of life in cancer patients.2 Therefore, body composition assessment is considered an essential part of clinical practice and physical diagnosis.3,4 Currently, a few non-invasive methods of body composition are used in clinical settings to screen for the global health status, FM and associated health risk of patients such as inspection (visual assessment), body weight, height, and their derivative body mass index (BMI).5 However, inspection lacks quantitative reliability, and BMI is an inaccurate diagnostic index particularly for

obesity.5 Not to mention that BMI may be misleading in diagnosing obesity in elderly people, since the elderly obese actually may suffer from cachexia; a condition called “sarcopenic obesity” .2 Medical conditions and diseases usually are associated with changes in the patient’s body composition. Any of these medical conditions/diseases is more likely to have its own specific body composition pattern. Detecting the subtle proportional differences of the body components associated with each disease could be a powerful tool of prediction and/or early detection of such disease. Based on this concept, a multiplicity of useful body composition indices and regression equations were introduced to the medical field that can be used by clinicians. Examples would include the lumbar skeletal muscle index, which is used among diagnostic criteria for cachexia, and FFM index, which is useful in identifying the degree of muscle loss.2 Also, the use of waist circumference (WC) and sagittal abdominal diameter regression equations to assess regional adiposity and fat distribution are other examples. Furthermore, increased WC and waist-to-hip ratio are independent risk factors for diabetes and cardiovascular disease.6,7 Having said that, the incorporation of such simple methods in the medical curriculum makes sense, as it may enable future physicians to alter the course of a disease by applying suitable preventive measures or early intervention to manage the disease.

Corresponding author: Yehia M.A-H. Marreez, MD, PhD, Department of Basic Medical Sciences, Touro University Nevada, 874 American Pacific Dr., Henderson, NV 89014, USA; Tel: +1 (702) 777-4782; Fax: +1 (702) 777-1799; email: [email protected]


The methodological advances in the field of body composition such as the use of whole body scan dual-energy x-ray absorptiometry (DEXA), regional CT scan, bioelectrical impedance (BIA), and body surface area (BSA) have proven successful in the prediction, diagnosis, treatment, follow-up, and prognosis of many disorders. Among these disorders are chronic diseases, cancers, HIV infections, and metabolic disorders such as obesity and its related comorbidities.1-4,8 BIA-derived phase angle values, for example, are strong prognostic indicators in advanced pancreatic cancer and independent prognostic indicators in stages IIIB and IV non-small cell lung cancer and other advanced cancers.9-13 Also, BSA and LBM are widely used in oncology to determine treatment dosing and calculate a safe starting dose.2 Meanwhile, body weight loss levels are key predictors of chemotherapeutic toxicity and shorter survival in lung cancer patients.14 To be emphasized, toxicity prediction in chemotherapy is a key success factor of cancer treatment, as anticancer drugs have a narrow therapeutic index. In chronic renal failure, BIA may prove valuable in decision-making of weight changes in renal dialysis patients, since dry weight and accurate hydration of these patients are critical aims of dialysis adequacy.15 As a prognostic tool, BIA also could be used to predict early and late mortality in hip fracture patients as an alternative to conventional nutritional assessment.16 Body composition analysis is of further interest in monitoring HIV-infected patients treated with protease inhibitors.17 Almost two-thirds of HIV patients receiving protease inhibitors develop peripheral lipodystrophy syndrome, which is associated with loss of FM, despite central fat accumulation, hyperlipidemia and insulin resistance in addition to LBM loss.18 In this respect, the non-invasive bioimpedance spectroscopy (BIS) method, which is less costly and easy to perform in clinical settings, may provide a valid alternative to monitor changes in LBM in HIV patients and other cachexia of chronic diseases.19 Inefficiency of Current Body Composition Teaching Body composition is a key player in most clinical specialties including internal medicine, endocrinology, oncology, nutritional and metabolic disorders, pediatrics, obstetrics, sports medicine and much more. However, body composition materials in medical school education are inadequate, quite dispersed and hardly detectable among the overwhelming amount of information in the medical curriculum.5 Also, the focus of the medical board exams on the body composition

concepts and methods is quite limited, and therefore they get the least attention by the medical students. As evidence, obesity is a convenient topic for clinical application of body composition principles and techniques. However, there was an apparent lag of proper medical attention and public awareness of overweight and obesity, considering that the problem still is growing to epidemic proportions in both adults and children in North America and parts of Europe.20 In our viewpoint, underestimation of and slow medical attention to obesity are due partially to inefficient teaching of body composition assessment in most of the medical curricula and may participate significantly in the increase of obesity syndrome. Lately, the higher health authorities in the United States realized the danger of high healthcare spending and that chronic disease accounts for over 75% of the United States’ national health expenditures.3 The rise in rates of overweight and obesity and their contribution to chronic illnesses sparked a renewed interest in the possible role for prevention to help control costs. We believe that emphasizing the importance of clinical body composition learning may enhance the awareness of medical students to such related problems and promote an effective role in the early intervention to decrease or even prevent obesity. However, it may need to be addressed pedagogically early at the medical and/or pre-medical graduate programs to enhance the students’ appreciation of the body composition field. The incorporation of clinical body composition as a separate course of the medical curriculum could be a valuable asset to the medical students and future family physicians. As well-known, one of the major roles of a family physician is early detection of potential health hazards such as obesity, cachexia, and osteoporosis, and their related comorbidities, preferably using simple, non-invasive, and inexpensive methods. This can be achieved via well-structured program of body composition assessment targeting medical students. Methods such as measuring skinfolds, body circumferences, BIA, their associated indices and regression equations, and their clinical interpretations are some examples of easy applicable and predictive techniques that medical students can learn as a part of their preclinical or clinical training.4

Proposed Design of “Clinical Body Composition” Course We may anticipate that the design of a human body composition course should be simple so as to mainly reflect the applicable and clinical aspects. The value of operationally simple, predictive, and diagnostic tools of measuring body composition, and their


impact on reducing the healthcare costs should be the main focus of the recommended course of “Clinical Body Composition”. Also, the prospects of potential clinical and basic research could be overviewed during the course, as this may open the door for potential refining of body composition techniques and their clinical applications. Subject to each school or program specific objectives, we may suggest that the clinical body composition course syllabus be divided into 3 main sections: 1. The first section may involve definitions,

classifications, different models of human body composition, and methods. The clinically applicable methods should be the main focus of this section. For example, the simple predictive and diagnostic methods that easily can be used in the clinics at minimal costs such as skinfold and circumference measurements to predict, for example, risk factors of some chronic disorders and cardiovascular incidents should be emphasized. Also, the clinical value of other non-invasive methods such as BIA, BIS, and near-infrared interactance, may be worthwhile exploring. An overview of the invasive techniques, but clinically important, such as DEXA, which is reliably used to diagnose “osteoporosis”, and regional CT scan usage in LBM loss may be included. However, the sophisticated techniques, which are used in advanced and highly specialized research centers and laboratories and still are under investigation, might be very briefly visited or not at all. Ultimately, the students may need to learn how to interpret the collected data and analyze commonly used regression equations in clinical settings.

2. The second section would include the study of

simple body composition calculations in healthy populations to be used as a reference. The students may need to know the normal ranges of body composition measurements in children, male and female adults, and elderly. Since the United States is populated with a diversity of different ethnic backgrounds such as Caucasians, Native Americans, African Americans, Hispanics, and Asians, it may be recommended to include a chapter for a brief review of the normal variations of body composition in different ethnic groups. This might project the basis of prevalence of certain disorders in one ethnic group more than the others.

3. In the third section, the students would be interested to learn pathological changes of body composition in sickness and disease. Clinically, multiple regression equations can be utilized to predict a variety of clinical disorders and/or estimate associated health risk.4,5 Combined with other data such as biomarkers, body composition parameters may become more informative to clinicians and more likely improve the performance of certain regression equations. For example, multiple regression models revealed that FM and LBM are significant predictors of the levels of circulating pigment epithelium-derived factor (PEDF), a predictor of metabolic health status in adults, independent of age, sex, and BMI.21 Also, increased BMI was found to be associated with plasma levels of highly sensitive C reactive Protein (hs-CRP) and vascular endothelial growth factor (VEGF), which are involved in the initiation and progression of atherosclerosis.22 On the other hand, WC was found to be better predictor of changes in high density lipoprotein-C (HDL-C), a lipoprotein that lowers the risk of atherosclerosis and heart disease, than BMI.23

Since the medical students usually are overwhelmed with a dense medical curriculum, the proposed body composition course might be offered as an “elective course” to medical students who may be interested or willing to pursue a career in primary care or family medicine, sports medicine, and others. Alternatively, body composition could be incorporated as a separate course in the Master’s Program of Health Sciences adopted by many American universities, such as Touro University Nevada, which prepare their graduates as potential students for medical schools. Although the University of Arizona teaches a body composition course, the philosophy and concept of that course are quite different from what is proposed here for several reasons. First, the course taught at the University of Arizona is tailed to fit in the nutritional science program, since the course is introduced as a part of nutritional science degrees. Second, the course is rather research oriented perhaps to prepare their students for a prospective research career. Third, the course is an undergraduate course which is quite extensive with less emphasis on the clinical applications that suit graduate medical students. To our knowledge, there is no medical school in any of the American universities that offers such clinically-oriented body composition program as an elective or integral part of their medical curricula.


Since quantification is the backbone of science, the knowledge of the principles of clinical body composition may provide the students with a quantitative analytical view of patients as regard to the three major components of body composition.24 This may perfectly fit in the holistic approach philosophy of practicing medicine, as a unique feature of osteopathic medical schools in the United States.

Conclusion Conditional to proper implementation, clinical body composition course could be a useful diagnostic and prognostic tool for clinicians. To this end, a specific course may be designed to medical or potential medical students as an addition to their curriculum. This course may provide students and future physicians with applicable insights of the scientific scope of the proportional body components in health and disease.

Notes on Contributors YEHIA MARREEZ, MD, PhD, is a Professor of Clinical Anatomy and Musculoskeletal Pathology in the Department of Basic Medical Sciences at Touro University Nevada, Henderson, NV, USA, along with being an orthopedic and hand surgeon.

Keywords applied, predictive, diagnostic, simple, inexpensive

References 1. Lavie CJ, Milani RV, Ventura HO, Romero-

Corral A. Body composition and heart failure prevalence and prognosis: getting to the fat of the matter in the "obesity paradox". Mayo Clin Proc. 2010 Jul;85(7):605-8.

2. Jacquelin-Ravel N, Pichard C. Clinical nutrition, body composition and oncology: A critical literature review of the synergies. Crit Rev Oncol Hematol. 2012 Apr 20. Article in press. [Epub ahead of print]. Accessed online on August 30, 2012.

3. Centers for Disease Control and Prevention. Rising Health Care Costs Are Unsustainable. April 2011.

4. Thibault R, Pichard C. The evaluation of body composition: a useful tool for clinical practice. Ann Nutr Metab. 2012;60(1):6-16.

5. Rourke KM, Kavey RE. Teaching medical school students total body composition assessment techniques in the diagnosis and treatment of obesity. J Am Diet Assoc. 1999 Aug;99(8):976-8.

6. Ricciardi R, Talbot LA. Use of bioelectrical impedance analysis in the evaluation, treatment, and prevention of overweight and obesity. J Am Acad Nurse Pract. 2007 May;19(5):235-41.

7. Chan DC, Watts GF, Barrett PH, Burke V. Waist circumference, waist-to-hip ratio and body mass index as predictors of adipose tissue compartments in men. QJM. 2003 Jun;96(6):441-7.

8. Stanley TL, Grinspoon SK. Body composition and metabolic changes in HIV-infected patients. J Infect Dis. 2012 Jun;205 Suppl 3:S383-90.

9. Gupta D, Lis CG, Dahlk SL, Vashi PG, Grutsch JF, Lammersfeld CA. Bioelectrical impedance phase angle as a prognostic indicator in advanced pancreatic cancer. Br J Nutr. 2004 Dec;92(6):957-62.

10. Gupta D, Lammersfeld CA, Vashi PG, King J, Dahlk SL, Grutsch JF, Lis CG. Bioelectrical impedance phase angle in clinical practice: implications for prognosis in stage IIIB and IV non-small cell lung cancer. BMC Cancer. 2009 Jan 28;9:37.

11. Paiva SI, Borges LR, Halpern-Silveira D, Assunção MC, Barros AJ, Gonzalez MC. Standardized phase angle from bioelectrical impedance analysis as prognostic factor for survival in patients with cancer. Support Care Cancer. 2010 Feb;19(2):187-92.


13. Santarpia L, Marra M, Montagnese C, Alfonsi L, Pasanisi F, Contaldo F. Prognostic significance of bioelectrical impedance phase angle in advanced cancer: preliminary observations. Nutrition. 2009 Sep;25(9):930-1.

14. Davis MP, Yavuzsen T, Khoshknabi D, Kirkova J, Walsh D, Lasheen W, Lagman R, Karafa MT. Bioelectrical impedance phase angle changes during hydration and prognosis in advanced cancer. Am J Hosp Palliat Care. 2009 Jun-Jul;26(3):180-7.

15. Ross PJ, Ashley S, Norton A, Priest K, Waters JS, Eisen T, Smith IE, O'Brien ME. Do patients with weight loss have a worse outcome when undergoing chemotherapy for lung cancers? Br J Cancer. 2004 May 17;90(10):1905-11.

16. Gallar-Ruiz P, Digioia C, Lacalle C, Rodríguez-Villareal I, Laso-Laso N, Hinostroza-Yanahuaya J, Oliet-Pala A, Herrero-Berron JC, Ortega-Marcos O, Ortiz-Libreros M, Mon-Mon C, Cobo-Jaramillo G, Vigil-Medina A. Body composition in patients on haemodialysis: relationship between the type of haemodialysis and inflammatory and nutritional parameters. Nefrologia. 2012 Jul 17;32(4):467-476.

17. Schiper L, Sadigursky D, Rosario DA, Schiper SP, Passos LC, Faintuch J. Hip fracture prognosis: could bioimpedance be an alternative to conventional nutritional assessment? Nutr Hosp. 2011 Jul-Aug;26(4):904-6.

18. Lo JC, Mulligan K, Tai VW, Algren H, Schambelan M. "Buffalo hump" in men with HIV-1 infection. Lancet. 1998 Mar 21;351(9106):867-70.

19. Carr A, Samaras K, Burton S, Law M, Freund J, Chisholm DJ, Cooper DA. A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors. AIDS. 1998 May 7;12(7):F51-8.

20. Van Loan MD, Strawford A, Jacob M, Hellerstein M. Monitoring changes in fat-free mass in HIV-positive men with hypotestosteronemia and AIDS wasting syndrome treated with gonadal hormone replacement therapy. AIDS. 1999 Feb 4;13(2):241-8.

21. Harris KC, Kuramoto LK, Schulzer M, Retallack JE. Effect of school-based physical activity interventions on body mass index in children: a meta-analysis. CMAJ. 2009 Mar 31;180(7):719-26.

22. Sunderland KL, Tryggestad JB, Wang JJ, Teague AM, Pratt LV, Zhang SX, Thompson DM, Short KR. Pigment epithelium-Derived Factor (PEDF) Varies with Body Composition and Insulin Resistance in Healthy Young People. J Clin Endocrinol Metab. 2012 Aug 28. Article in press. [Epub ahead of print]. Accessed online on August 30, 2012.

23. Siervo M, Ruggiero D, Sorice R, Nutile T, Aversano M, Iafusco M, Vetrano F, Wells JC, Stephan BC, Ciullo M. Body mass index is directly associated with biomarkers of angiogenesis and inflammation in children and adolescents. Nutrition. 2012 Mar;28(3):262-6.

24. Arimura ST, Moura BM, Pimentel GD, Silva ME, Sousa MV. Waist circumference is better associated with high density lipoprotein (HDL-c) than with body mass index (BMI) in adults with metabolic syndrome. Nutr Hosp. 2011 Nov-Dec;26(6):1328-32.

25. Ockenga J, Manns MP. The impact of body composition analysis in HIV-infected patients: quantifying therapeutic effects. AIDS. 1999 Feb 4;13(2):279-80.





Mapping of Medical Microbiology Content in a Clinical Presentation Curriculum

Robin K. Pettit & Yen-Ping Kuo A. T. Still University, School of Osteopathic Medicine in Arizona, Mesa, AZ, USA

Abstract Clinically important microbes, and the pathogenesis, symptoms and diagnosis of their corresponding infectious diseases were integrated into clinical schemes within a clinical presentation curriculum. Decisions on microbe placement considered a variety of factors, including spaced reinforcement of major pathogens. We report here the map of our integrated medical microbiology curriculum.

The pervading trend in medical education is integration of formal knowledge with clinical experience. A strong rationale for this approach is that student retention of non-contextualized basic science information is poor.1-6 Indeed, students who learn symptoms of a disease in the context of biomedical information are better able to retain their diagnostic performance over time than those who learn disease symptoms in isolation.7-9 A. T. Still University’s School of Osteopathic Medicine in Arizona (ATSU SOMA) considered this critical issue when designing the curriculum. The SOMA program includes an integrated clinical presentation curriculum (CPC), and early contextual learning experiences.10-12 Our students learn to diagnose using inductive reasoning through investigation of clinical schemes that represent the most common presenting signs or symptoms (e.g. abdominal pain). Schemes provide a framework that students can use for both learning and problem solving, and reveal the road map that an expert clinician uses in an inductive decision-making process.10,13 Thus, the schemes serve two purposes, to organize learning and to solve clinical problems.14 In SOMA’s CPC, 131 schemes are organized into 11 organ system courses that are sequenced through the student’s first two years. Instruction in basic,

clinical and social sciences occurs within each scheme. Figure 1 shows the sequence of the courses in years 1 and 2, in addition to Medical Skills and Osteopathic Principles and Practice courses run in parallel. Year 1 begins with Principles of Medicine, where students learn basic science fundamentals in the context of clinical scenarios. As an example, bacterial endospores are introduced in a clinical scenario where a patient receives a tetanus booster after falling off a horse and fracturing her radius and ulna. Students are introduced to their first scheme, Sore Throat/Rhinorrhea, toward the end of Principles of Medicine. For medical microbiology, clinically important microbes, and the pathogenesis, symptoms and diagnosis of their corresponding infectious diseases are integrated into the schemes within each organ system. As summarized in Table 1 (see Appendix), the medical microbiology content, presented in the context of infectious diseases, is integrated into 47 schemes housed within 8 organ systems. Decisions on optimum placement of medical microbiology topics are multifactorial. At the outset, a comprehensive list of objectives/content topics is formulated. The layout takes into account significance to the scheme, and whether the topic has been identified by USMLE, COMLEX and published medical microbiology core knowledge objectives.15 Integration with other basic science and clinical knowledge disciplines is coordinated. Because spaced repetition promotes retention of knowledge and improvement of clinical skills, a critical consideration in placing medical

Corresponding author: Robin K. Pettit, Ph.D., Yen-Ping Kuo, Ph.D., A. T. Still University, School of Osteopathic Medicine in Arizona, 5850 E. Still Circle, Mesa, AZ 85206, USA. Tel: (480) 248-6004, Fax: (480) 219-6159, Email: [email protected]; [email protected]


microbiology topics within the schemes is opportunity for review of major human pathogens.16-21 Placement of a major pathogen in multiple schemes and courses allows us to reinforce and build on material presented initially. When a pathogen is first introduced within a relevant scheme, its general characteristics and epidemiologic and clinical significance are discussed. Features such as growth characteristics, virulence factors and immune responses associated with that particular clinical presentation are emphasized. When the organism is revisited under other schemes, characteristics relevant to that clinical presentation are covered. Figure 2 provides an example of the distribution of Staphylococcus characteristics across the courses. The guiding principle here resembles that of Wilkerson et al., who have developed an ascending spiral pre-clerkship curriculum in which content is purposively repeated at a higher level of complexity.21 The layout of our map also reflects intentional review of major pathogens prior to board exams. Features of Pseudomonas aeruginosa infection, for example, are covered in five courses over the 2-year period (Table 1, see Appendix), with a final review in Dermatology (Figure 1). Basic concepts and recurring themes in medical microbiology are woven throughout years 1 and 2 of the curriculum. For example, the role of biofilms in the pathogenesis and treatment of joint infections, endocarditis, catheter infections, periodontitis, vaginitis and otitis media is addressed in the Neuromusculoskeletal, Cardiopulmonary, Renal and Endocrine, Gastrointestinal, Genitourinary, and Senses courses, respectively. Lipopolysaccharide (LPS) is another example of a recurring topic. After students grasp LPS structural features and their relationship to disinfectant and antibiotic resistance in Principles of Medicine, the role of LPS in immune evasion and the pathogenesis and symptoms of gram-negative infections is discussed in multiple courses. Another major recurring theme is the predominance of human infection due to normal microbiota, which maps readily to all of the courses. Our strategy is designed to aid in the transfer of basic science knowledge to clinical learning. In transfer, a concept learned in one context is used to solve a problem in a different context, and this phenomenon is enhanced when multiple examples are provided.22 In addition to facilitating transfer, the reinforcement of medical microbiology principles over time within a clinical context likely facilitates long-term retention of the substantial amount of microbiology knowledge medical students must acquire.16-21

Figure 1. Sequence of organ system courses in years 1 and 2. Box size is proportionate to the length of each course. Students receive training in Medical Skills and Osteopathic Principles and Practice throughout years 1 and 2. Biostatistics and epidemiology is integrated throughout year 2.

Delivery of didactic content in our year 1 curriculum reflects the diverse styles of the basic science and clinical faculty involved in each organ system. Multiple approaches, including flipped classrooms, problem based learning, case studies, gallery walks, interactive clicker sessions, games, and traditional lectures are employed. ATSU SOMA MS years 2-4 train in a contextual setting at and around one of eleven community campuses nationwide (each affiliated with the National Association of Community Health Centers), and thus receive didactic content via podcasts.11,12 As there are no CPC textbooks, content resources are similar to those at institutions with more traditional curricula. Incoming students receive a list of 22 required textbooks which are used throughout their first two


years. For medical microbiology, we require a single non-clinical microbiology text, and recommend an organ-system based microbiology text for clinical correlates. The current lack of CPC-based texts requires faculty to carefully structure their presentations around particular schemes. One drawback to a CPC, particularly in a relatively new program such as ours, is that scheme details and the sequence of the organ systems are not static. Placement of microbes evolves with new knowledge and with changes in sequencing of the organ systems. However, the availability of a template facilitates this process enormously. Teamwork within the discipline and across disciplines is essential; flexibility and communication are absolute requirements! Another drawback is the need to condense information within an integrated course that contains both basic science and clinical components; however, this is an issue with any integrated curriculum. Faculty need to be mindful that students may have difficulty keeping track of the big picture for a particular

discipline. Finally, it’s challenging to find the optimum location to cover microbes like Staphylococcus and Streptococcus that cause important infections in multiple organ systems, and emerging infections like hantavirus that cause divergent symptoms. In providing a clinical framework for two years of basic science instruction and small group case work, the scheme-based clinical presentation model is likely motivating for students, and may enhance understanding, long-term retention and clinical problem solving skills. The Infectious Diseases Society of America Preclinical Curriculum Committee now advocates a medical education approach that facilitates transfer of classroom knowledge to the bedside.23 SOMA’s integrated medical microbiology content is an excellent example of such an approach. Our medical microbiology map may be of value to other programs interested in developing a scheme-based CPC.

Figure 2. Distribution of Staphylococcus topics across the curriculum. Clinically important members of the genus are introduced/reviewed in eight of the 47 schemes, and in all but one (Hematology) of the organ systems that include medical microbiology content. Basic characteristics, including morphology and gram-stain reaction, are reviewed in each of these schemes. Schemes are underlined. NMSK= neuromusculoskeletal, CP= cardiopulmonary, REM= renal and endocrine, GI= gastrointestinal, GU= genitourinary.


Notes on Contributors ROBIN K. PETTIT, PhD, is a Professor of Microbiology at A.T. Still University, School of Osteopathic Medicine in Arizona, Mesa, AZ, USA. YEN-PING KUO, PhD, is a Professor of Microbiology at A. T. Still University, School of Osteopathic Medicine in Arizona, Mesa, AZ, USA

Keywords Medical microbiology, scheme, clinical presentation curriculum, integration, basic science

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Retention of basic science information by fourth-year medical students. Acad Med. 1996; 71: S80-S82.

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Appendix Table 1. Medical microbiology content mapped to 47 schemes and eight courses. aIntroduction to Medical Microbiology includes classification, normal microbiota, fundamentals of bacteriology, mycology, parasitology and virology, and introduction to microbial pathogenesis and diagnosis. bEtiologies in bold: introduction/content relevant to clinical presentation; etiologies in non-bold: review/content relevant to clinical presentation; etiologies in parentheses: mentioned but not discussed.


Organ System/ Course

Principles of Medicine Neuro-

Musculoskeletal I (Musculoskeletal System Emphasis)

Clinical Scheme

None Sore Throat/ Rhinorrhea

Pain Nociceptive Upper Extremity Pain Nociceptive Lower Extremity

Lump/Mass Musculo-skeletal

Spinal Pain

Infectious Disease/

Topic

Introduction to Medical Microbiology

b

pharyngitis diphtheria common cold hand-foot-mouth disease mononucleosis

cellulitis necrotizing fasciitis pyomyositis myonecrosis osteomyelitis

joint infection Lyme disease

viral oncogenesis: sarcoma, papillomas,

etc.

tuberculosis

Microbea

Clostridium tetani (Herpes simplex 1 virus, human papillomavirus)

bacteria: Streptococcus pyogenes (and Group C&G) Corynebacterium diphtheriae

(Neisseria gonorrhoeae, Haemophilus influenzae, Treponema pallidum, Mycoplasma pneumoniae, Chlamydophila pneumoniae)

viruses: Rhinovirus Non-Rhinovirus enteroviruses Coronavirus Adenovirus HSV Epstein-Barr virus (Influenza virus, Parainfluenza virus, Respiratory syncytial virus, Cytomegalovirus)

Staphylococcus aureus S. pyogenes C. perfringens Actinomyces spp. Nocardia spp. Pseudomonas aeruginosa H. influenzae Eikenella corrodens Pasteurella spp. Brucella spp. Bartonella spp.

S. aureus S. epidermidis N. gonorrhoeae

Borrelia burgdorferi

EBV HPV Human herpes virus-8 Human T-cell lymphotropic virus JC virus BK virus

Mycobacterium tuberculosis


Neuro-musculoskeletal II (Neurological System Emphasis)

Clinical Scheme

Headache Acute Neurological Deficits

Seizures

Cognitive Impairment

Weakness

Infectious Disease/

Topic

acute and chronic meningitis encephalitis brain abscess

neuro-cysticercosis

prion disease AIDS syphilis

progressive multifocal leukoencephalopathy West Nile disease polio, botulism

Microbea

bacteria: S. pneumoniae S. agalactiae N. meningitidis Listeria monocytogenes (H. influenzae, M. tuberculosis, Escherichia coli)

viruses: Non-Rhinovirus enteroviruses Herpesviruses Arboviruses Rabies virus

fungus: Cryptococcus spp. parasite: Taenia solium

Toxoplasma gondii

prion Human immunodeficiency virus T. pallidum

JVC and BKV West Nile Virus Poliovirus C. botulinum



Cardiopulmonary

Renal and Endocrine

Clinical Scheme Abnormal

Heart Sounds Dyspnea Cough

Urinary Frequency

Hyperglycemia

Infectious Disease/

Topic Endocarditis

upper respiratory tract infections: rhinitis pharyngitis laryngitis epiglottitis croup

lower respiratory tract infections: bronchitis bronchiolitis typical, atypical, community- acquired, nosocomial pneumonia

urethritis cystitis prostatitis pyelonephritis

rhinocerebral mucormycosis necrotizing otitis externa emphysematous UTIs emphysematous cholecystitis diabetic foot infections necrotizing fasciitis type 1

Microbea

viridans streptococci Enterococcus spp. Kingella kingae Coxiella burnetii (S. aureus, S. epidermidis)

bacteria: Bacillus anthracis Bordetella pertussis Acinetobacter spp. S. pneumoniae H. influenzae P. aeruginosa M. tuberculosis M. pneumoniae Chlamydia spp. Legionella pneumophila (Nocardia spp. S. aureus)

viruses: Influenza virus Parainfluenza virus RSV Mumps virus Coronavirus Rhinovirus Adenovirus systemic mycoses: Histoplasma capsulatum Blastomyces dermatitidis Coccidioides immitis Paracoccidioides brasiliensis opportunistic mycoses: C. neoformans Aspergillus fumigatus Rhizopus and Rhizomucor spp. Pneumocystis jirovecii

E. coli S. saprophyticus Klebsiella pneumoniae Proteus mirabilis Enterobacter spp. Serratia spp. Candida albicans (S. epidermidis, E. faecalis P. aeruginosa)

Rhizopus oryzae P. aeruginosa (E. coli, C. perfringens, Klebsiella spp., streptococci, enterococci, Peptostreptococcus spp., Prevotella spp., Porphyromonas spp., Bacteroides fragilis group, Clostridium spp., S. aureus)



Gastro-Intestinal

Clinical Scheme Oral

Complaints Dysphagia

Abdominal Pain

GI Bleeding

Jaundice, Abnormal

Liver Enzymes

Anal Discomfort Diarrhea Nausea

and Vomiting

Infectious Disease/

Topic

caries periodontal disease cervicofacial actinomycosis oropharyngeal esophageal candidiasis

pharyngitis peritonsillar abscess

intra- abdominal abscess gastroenteritis

gastric and duodenal ulcers

viral hepatitis chlonorchiasis fascioliasis

perianal cellulitis perirectal, perianal abscess intestinal helminth infections

acute diarrhea chronic diarrhea traveler's diarrhea hemolytic uremic syndrome dysentery pseudomembranous colitis

bacterial toxin-related foodborne disease

Microbea

LactobacillusBacteroides viridans streptococci A. israelii C. albicans (Fusobacterium)

S. pyogenes H. influenzae C. diphtheriae EBV Coxsackie A virus (C. albicans, CMV, S. aureus, anaerobic mouth flora)

Bacteroides fragilis Norovirus Rotavirus Astrovirus Adenovirus

Helicobacter pylori

hepatitis viruses A, B, C, D, E Opisthorchis sinensis Fasciola hepatica

(S. pyogenes, E. coli, Enterococcus, Bacteroides, Staphylococcus spp.) nematodes: Strongyloides stercoralis Necator americanus Ancylostoma duodenale Ascaris lumbricoides Enterobius vermicularis Trichuris trichiura cestodes: Taenia solium Taenia saginata Diphyllobothrium latum

bacteria: Salmonella spp. Shigella spp. Campylobacter jejuni invasive E. coli toxigenic E. coli Vibrio cholerae Vibrio parahaemolyticus Yersinia enterocolitica C. difficile protozoa: Entamoaeba histolytica Giardia lamblia Cryptosporidium spp. (Norovirus, Rotavirus, Adenovirus, Astrovirus)

B. cereus C. botulinum S. aureus



Genitourinary I

Clinical Scheme Pap Smear Vaginal Discharge/Discomfort Pelvic Pain Scrotal Mass

Infectious Disease/

Topic

genital warts

vaginitis urethritis cervicitis genital ulcers: genital herpes chancroid syphilis lymphogranuloma venereum granuloma inguinale

pelvic inflammatory disease epididymitis epididymoorchitis

Microbea

HPV

Gardnerella vaginalis Trichomonas vaginalis H. ducreyi C. trachomatis K. granulomatis

N. gonorrhoeae T. pallidum Mycoplasma spp. C. albicans HSV

A. israelii (N. gonorrhoeae, C. trachomatis, Chlamydia trachomatis, Bacteroides, anaerobic streptococci, M. hominis)

mumps virus (C. trachomatis, N. gonorrhoeae, E. coli, Brucella spp., M. avium complex, opportunistic yeasts)


Genitourinary II

Clinical Scheme Pregnancy Antepartum Pregnancy

Loss Non-Reassuring

Fetal Status Labor

Breast Disorders

Urinary Incontinence

Infectious Disease/

Topic

TORCH perinatal infections

spontaneous abortion

chorioamnionitis UTI and RTI during pregnancy

postpartum infections:

endometritis wound infections perineal cellulitis respiratory complications UTIs, mastitis septic pelvic phlebitis

mastitis breast abscess

STI-related UTI non-STI-related UTI

Microbea

T. gondii T. pallidum HSV, VZV, CMV HBV Parvovirus B19 Rubella virus (Coxsackievirus)

S. agalactiae L. monocytogenes HIV

Measles virus Non-Rhino enteroviruses

Enterobacteriaceae Influenza virus (Bacteroides spp., S. agalactiae, E. coli, Candida, Ureaplasma urealyticum)

Mycoplasmataceae

Staphylococcus spp.

(N. gonorrhoeae, C. trachomatis, Trichomonas, all common UTI etiologies)



Senses Hematology

Clinical Scheme Ear Pain, Tinnitus

Hearing Loss Eye Redness

Smell and Taste Dysfunction

Anemia

White Blood cell Abnorm-

alities

Lymph-adenopathy

Recurrent/ Persistant Infections

Infectious Disease/

Topic

otitis media otitis externa necrotizing otitis externa

blepharitis dacryocystitis orbital cellulitis bacterial conjunctivitis viral conjunctivitis trachoma loiasis keratitis onchocerciasis endophthalmitis

viral rhinosinusitis bacterial rhinosinusitis fungal rhinosinusitis rhinocerebral mucormycosis

infection- related hemolysis: malaria babesiosis sepsis

adult T-cell leukemia- lymphoma/ lymphocytic leukemia

infection-related general and localized lymphadenopathy: leptospirosis Lyme disease tularemia brucellosis bubonic plague African trypanosomiasis Chagas' Disease leishmaniasis anthrax sporotrichosis

immune-evasion mechanisms microbial drug resistance (review

bacterial cell wall, bacterial genetics) AIDS innate immunity- deficit related infections adapted immunity- deficit related infections healthcare-associated infections biofilm infections

Microbea S. pneumoniae

nontypeable H. influenzae, P. aeruginosa Moraxella catarrhalis (S. aureus, Candida, Aspergillus spp.)

Onchocerca volvulus Loa loa Adenovirus HSV S. aureus (S. epidermidis, S. pneumoniae, nontypeable H. influenzae, M. catarrhalis, N. gonorrhoeae, C. trachomatis, P. aeruginosa, Acanthamoeba, gram-negative bacilli, B. cereus, Aspergillus spp., C. albicans)

Rhizopus oryzae Aspergillus spp. (Rhinovirus, Influenza virus, Parainfluenza virus, S. pneumoniae, nontypeable H. influenzae, M. catarrhalis, Fusarium, Mucorales)

Plasmodium spp. Babesia spp. C. perfringens

HTLV (HIV)

Leptospira spp. Borrelia spp. Francisella tularensis Brucella spp. Yersinia spp. Bacillus anthracis Trypanosoma spp. Leishmania spp. Sporothrix schenckii

HIV P. aeruginosa



Dermatology

Clinical Scheme Burns Macular Skin Rash Papules/ Plaques

Blisters Scalp

Disorders Pruritis

Infectious Disease/

Topic

burn infections

scarlet fever STSS TSS rheumatic fever secondary syphilis folliculitis furunculosis skin abscess impetigo erysipelas SSSS

Rocky Mountain Spotted Fever endemic typhus childhood viral exanthems tinea versicolor tinea nigra

fish tank granuloma leprosy erythrasma papules/plaques due to hematogeous dissemination dermatophytoses cutaneous candidiasis sporotrichosis cutaneous warts molluscum contagiosum pityriasis rosea acne

zoster oropharyngeal herpes traumatic herpes hand, foot and mouth disease smallpox

folliculitis tinea capitis piedra

pediculosis scabies

Microbea

P. aeruginosa

S. pyogenes S. aureus T. pallidum (P. aeruginosa)

Rickettsia rickettsii R. prowazekii R. typhi Malassezia furfur Hortaea werneckii Measles virus Rubella virus Parvovirus B19 VZV HHV-6

M. marinum M. leprae Propionibacterium acnes C. minutissimum Microsporum spp. Trichophyton spp. Epidermophyton spp.

N. gonorrhoeae N. meningitidis C. albicans Sporothrix schenckii HPV HHV molluscum contagiosum virus

VZV HSV Coxsackievirus Variola virus Vaccinia virus

(Malassezia, mites, T. tonsurans, M. canis, Trichosporon spp., Piedraia hortae, S. aureus, P. acnes)

Pediculus capitis Phthirus pubis Pediculus corporis Sarcoptes scabiei var. hominis





The Effect of a Graduate-Level Course on Health Care for the Urban Underserved on

Student Knowledge, Attitudes, and Perceptions

Casey M. Rebholz1, Lydia A. Bazzano1,2 & Benjamin Springgate3 1Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA 2Ochsner Medical Center, New Orleans, LA, USA 3Tulane University School of Medicine, New Orleans, LA, USA.

Abstract The “Health Care for the Urban Underserved” course was developed to prepare students to provide services to underserved populations. Student knowledge, attitudes, and perceptions were assessed. This graduate-level course improved knowledge about the problems of the underserved and improved self-efficacy with respect to working with the underserved.

Student-run clinics and other community-academic service initiatives address unmet health and social service needs of underserved populations.1 Health professional students are actively involved in these programs and evidence suggests that their participation impacts their choice of future careers.2-6 There were previously no graduate-level courses at our institution with the principal focus of preparing pre-clinical medical and public health students to work with underserved populations to improve their health and health care. The “Health Care for the Urban Underserved” elective course was developed to provide to medical and public health students with an introduction to issues surrounding healthcare for urban underserved populations, with a focus on New Orleans. The course was designed to complement the community service efforts of student-run clinics and related programs. Course requirements consisted of independent readings, in-class discussions, presentations from community leaders and faculty, a community project, and reflection. There were seven weekly two-hour in-class meetings. Course meeting topics included an

overview of health care for the urban underserved, social determinants of health, and health disparities; student-run clinics and associated programs; community medicine and the patient-centered medical home model; substance abuse, mental health, and physical health; homelessness and housing stability; racial and ethnic populations in New Orleans; cultural awareness; and community-academic partnerships. Guest faculty lecturers and community leaders presented during the class meetings and moderated class discussions. Guest speakers were identified by the course director through their involvement as community partners or volunteers of the student-run clinics. The last class meeting was dedicated to student community project presentations and reflection. The written reflection was intended to promote personal development as health professionals, and emphasized how the students felt about encounters with patients and the community-academic service initiatives, what they learned, and how community members served as teachers. The minimum length of the written reflection was 500 words, and time expected for completion was one hour. The purpose of the community project was to provide a structured, mentored opportunity to serve the community through student-run clinics. Student projects were meant to stimulate program development and evaluation for existing community-academic service initiatives. Projects

Corresponding author: Casey M. Rebholz, PhD, MPH, Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2000, New Orleans, LA 70112, USA; Tel: +1 504-233-2877; Fax: +1 504-988-1568; email: [email protected].


were conceived and completed by students in collaboration with a student clinic representative and community partner representative. Students were permitted to work individually or as a group. Students presented about their project and submitted a final report during the last in-class meeting. Community projects completed by the students included: design of a substance addiction and sleep survey; participation in a city-wide health and social service fair for the homeless in New Orleans; development of an electronic intake record system for a homeless shelter; production of a promotional video for a student-run clinic; development and distribution of health education materials; presentation and discussion of a case report; needs assessment for HIV counseling and testing at student-run clinics; and proposal for a new student-run clinic at a substance abuse treatment facility. The approximate amount of time spent completing the course project, final report, and presentation ranged from 2 to 10 hours. Study participants consisted of medical and public health students, 18 years of age or older, enrolled in a new course entitled “Health Care for the Urban Underserved” during the fall 2011 semester. Study participants completed a 21-item assessment form at the first and last class meeting. Study participants were asked to indicate their level of agreement with statements relating to their knowledge, attitudes and perceptions on a 7-item Likert scale with the following categories: disagree very strongly (1), disagree strongly (2), disagree (3), neutral (4), agree (5), agree strongly (6), and agree very strongly (7). The assessment form was adapted with permission from the Medical Students’ Attitudes Toward the Underserved (MSATU) survey.7,8 A Wilcoxon rank sum test was performed to compare scores before and after the course using SAS 9.2 statistical software (SAS Institute, Inc., Cary, NC). Statistical significance was assessed at an α level of 0.05. The institutional review board approved the study protocol. The majority of students were female (76%), which reflects the demographic distribution of public health students. More public health students (76%) than medical students (24%) took the course. Twenty-six students completed the assessment form at the beginning of the course, and 16 students completed the assessment form at the end of the course. Of the ten students that completed the assessment at the beginning but not at the end of the course, one student did not attend the last class meeting and nine students did not complete the entire course.

Table 1 (Appendix) provides mean response scores before the course (n=26) and after the course (n=16). There was a statistically significant increase in agreement scores for four of the 21 items: knowledge about the problems of underserved individuals (net change=0.64, p=0.03), knowledge about the problems of the homeless (net change=1.08, p=0.002), feeling capable of working with underserved individuals (net change=0.55, p=0.05), and feeling capable of working with the homeless (net change=0.72, p=0.03). The change in agreement scores was not statistically significant for any other statements. Scores increased over time for 20 out of 21 statements, and remained the same for one statement regarding the belief that everyone should have access to emergency medical care regardless of ability to pay. Students reported the highest level of agreement with statements indicating an interest in working with the underserved after graduation, believing that everyone should have access to childhood immunizations, and believing that everyone should have access to emergency medical care. Many undergraduate medical students provide volunteer service to medically underserved populations, particularly during the pre-clinical years.1-3,5,6 Previous research has demonstrated that social medicine curricula have been successfully incorporated into residency training and may better prepare medical residents to provide health care for underserved populations, within the context of social and cultural issues.9-11 However, to the best of our knowledge, structured educational programs in social medicine for pre-clinical health professional students have not previously been described or evaluated. This report documents the design and implementation of a course to complement ongoing service learning activities with urban, medically underserved populations. The community perspective remained central in the curriculum through involvement of representatives from community-academic service initiatives and outreach programs in class discussions and with student projects. This course appeals to students interested in a future career with these populations and those who believe in providing health services regardless of income status of patients. This new graduate-level course improved knowledge about and feeling capable of working with underserved and homeless individuals. This finding is consistent with a qualitative evaluation of medical interns and residents which reported that a service-oriented social medicine curriculum improved understanding of problems of underserved


individuals and enhanced their skills in working with underserved individuals.11 Two studies reported that attitudes toward the medically underserved became less favorable over the duration of medical school.7,8 The previously documented decline in interest and confidence toward working with underserved populations during medical training underscores the need for implementing courses similar to that described in this article. There are a few limitations of this study. Thirty-five percent (9/26) of students did not complete the course. The primary reason for dropping the course was the higher number of requirements and greater amount of time spent outside of class meetings than anticipated. The number of students expressing interest and the number completing the course was remarkable for the first offering of an elective. However, the sample size and power was limited for detecting statistically significant change. The study population represents students that choose to take an elective on urban underserved medicine, and may not be generalizable to all medical and public health students. Future directions include streamlining the course requirements and merging the course with an existing public health course to supplement the original learning objectives with training in health care management. More credit hours will be granted to align better with the course requirements. In addition to being offered to public health and medical students, the course has also been approved for academic credit for social work students. Community projects completed by students during the course will be incorporated into student-run clinics and other community-based health and social service initiatives. Future studies could assess post-graduate employment and volunteer activities with underserved populations to ascertain long-term effects of this course.

Acknowledgements The authors would like to thank faculty and community leader guest lecturers, past and present leaders of the student-run clinics, the Interclinic Council, and community-academic service initiatives, including Ozanam Inn homeless shelter, Bridge House rehabilitation facility, and Fleur de Vie clinic.

Notes on Contributors CASEY M. REBHOLZ, PhD, MPH, is a research fellow in the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, co-founder of the student-run Ozanam Inn Weekend Clinic, and director of this course. LYDIA A. BAZZANO, MD, PhD, MPH, is an associate professor in the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, attending physician at Ochsner Medical Center, and faculty advisor for this course. BENJAMIN SPRINGGATE, MD, MPH, is a clinical assistant professor in the Departments of Medicine and Psychiatry, Tulane University School of Medicine, medical director at St. Thomas Community Health Center, physician volunteer at Tulane student-run clinics, and faculty advisor for the Interclinic Council.

Keywords Community health services, curriculum, medical students, public health students


References 1. Simpson SA, Long JA. Medical student-run

health clinics: important contributors to patient care and medical education. J Gen Intern Med. 2007;22(3):352-356.

2. Eckenfels EJ. Contemporary medical students' quest for self-fulfillment through community service. Acad Med. 1997;72(12):1043-1050.

3. Haq CL, Cleeland L, Gjerde CL, Goedken J, Poi E. Student and faculty collaboration in a clinic for the medically underserved. Fam Med. 1996;28(8):570-574.

4. Ko M, Edelstein RA, Heslin KC, Rajagopalan S, Wilkerson L, Colburn L, Grumbach K. Impact of the University of California, Los Angeles/Charles R. Drew University Medical Education Program on medical students' intentions to practice in underserved areas. Acad Med. 2005;80(9):803-808.

5. O'Toole TP, Hanusa BH, Gibbon JL, Boyles SH. Experiences and attitudes of residents and students influence voluntary service with homeless populations. J Gen Intern Med. 1999;14(4):211-216.

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8. Crandall SJ, Davis SW, Broeseker AE, Hildebrandt C. A longitudinal comparison of pharmacy and medical students’ attitudes toward the medically underserved. Am J Pharm Educ. 2009;72(6):1-8.

9. Fornari A, Anderson M, Simon S, Korin E, Swiderski D, Strelnick AH. Learning social medicine in the Bronx: an orientation for primary care residents. Teach Learn Med. 2011;23(1):85-89.

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Appendix

Table 1: Mean Response Scores on 7-item Likert Scale Before and After Participating in the “Health Care for the Urban Underserved” Elective

Assessment Form Statement Before (n=26)

After (n=16)

Difference P-value

I am knowledgeable about the problems of underserved individuals.

5.23 5.88 0.64 0.03

I am knowledgeable about the problems of the homeless. 4.73 5.81 1.08 0.002

I feel capable of working with underserved individuals. 5.39 5.94 0.55 0.05

I feel capable of working with the homeless. 5.15 5.88 0.72 0.03

Everyone should have access to emergency medical care regardless of their ability to pay.

6.69 6.69 0.00 0.84

Everyone should have access to childhood immunizations regardless of their ability to pay.

6.65 6.75 0.10 0.91

I am interested in working with the underserved after I graduate.

6.27 6.56 0.29 0.40

State governments should be responsible for funding programs to meet health care needs of its residents.

6.19 6.44 0.25 0.18

Medical care should be provided without charge for those who cannot pay.

6.04 6.44 0.40 0.19

Everyone should have access to medications for chronic illness regardless of their ability to pay.

6.00 6.44 0.44 0.13

I believe I can make a difference working with the underserved.

5.92 6.00 0.08 0.83

I feel comfortable working with underserved individuals. 5.81 6.00 0.16 0.60

Everyone should have access to cancer treatment regardless of their ability to pay.

5.73 5.94 0.21 0.56

I feel personally responsible for providing medical care to the needy.

5.58 6.00 0.42 0.29

Everyone should have access to open heart surgery regardless of their ability to pay.

5.58 6.00 0.42 0.32

I feel comfortable working with the homeless. 5.50 6.00 0.50 0.16

Everyone should have access to heart transplants regardless of their ability to pay.

5.50 5.88 0.38 0.40

Health care providers should volunteer their time working in a free clinic.

5.40 6.06 0.66 0.07

I am skilled in working with underserved individuals. 4.73 4.88 0.14 0.90

I am interested in working in a primary care setting. 4.73 4.88 0.14 0.72

I am skilled in working with the homeless. 3.96 4.81 0.85 0.08




ORIGINAL RESEARCH

Challenging Medical Students to Confront their Biases: A Case Study Simulation Approach

Lon J. Van Winkle1, Sophie La Salle1, Lendell Richardson2,

Bryan C. Bjork1, Paulette Burdick1, Nalini Chandar1, Jacalyn M. Green1, Sean M. Lynch1, Chester Robson1 & Susan M. Viselli1 1Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA 2College of Health Sciences, Midwestern University, Downers Grove, IL, USA

Abstract We used three approaches to determine whether first-year medical students would begin to confront their biases in response to a simulated encounter with an incarcerated, African-American patient. The patient presented with fatigue in a Biochemistry course workshop. Two hundred five students watched and helped a classmate conduct a simulated interview with the patient who had been imprisoned for attempted murder. We then studied whether the students confronted their biases against the patient using (a) a survey of individual students regarding these biases, (b) one of a number of questions on a formal assignment concerning the case completed in a team format, and (c) an unprompted extra-credit opportunity to reflect as a team on issues of their choice. On the survey, eighty five percent of students confronted their biases against the patient, and they began to reflect critically about these biases. Critical reflection on teams occurred more frequently outside the formally assigned exercise (Effect Size = 0.75, crucial practical importance). Thus, most first-year medical students can be led, even in basic sciences courses, to confront their biases. In this way, they may also begin to mitigate their biases against patients. Such self-regulation of biases by health care professionals on a regular basis should help to decrease health care disparities.

Introduction Unexamined and unmitigated biases of health care professionals against patients contribute to health care disparities.1 While many disparities may be attributable to other factors, such as socioeconomic status, provider biases contribute independently.2,3 In response, patients may have or develop their own biases which cause them to seek care less often or adhere less strictly to treatment plans.4,5 Health care professionals should be able to identify their biases through critical reflection (CR).6-10 Exercises which have been used to foster such reflection in health care professional students include reading poems written by physicians, watching a performance on the challenges of aging and considering the roles of other professionals in

health care.7,9,10 Students then discuss and reflect on each of these experiences within the safety of a familiar learning team.6 The deepest CR by students and their teams seems to have occurred not within the framework of formal assignments, but rather, during optional opportunities to perform CR on topics chosen by the student teams.7 By confronting their biases in these ways on a regular basis, students could become inclined to look for their biases as part of their professional routine. If healthcare professionals identify their biases they can also develop the ability to mitigate them and, thus, to deliver better patient care with fewer health care disparities.1 However, our students were not asked explicitly to attempt to identify their biases against patients in any of these exercises. For these reasons, we wanted to determine whether first-year medical students would identify and confront their biases in response to a simulated encounter with an incarcerated, African-American patient with a chief complaint of relatively new-

Corresponding author: Dr. Van Winkle, Department of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, 555 31st Street, Downers Grove, Illinois, 60515, USA; Tel: +1 (630) 515-6153; Fax: +1 (630) 515-6319; email: [email protected]


onset fatigue. Because we wanted students to identify their own biases, we did not indicate which biases they might already have against the patient. Instead, we left it to the students to identify their biases in response to the patient. Students were surveyed specifically about their biases separately from a workshop exercise concerning the patient. This exercise was designed to help students understand the patient’s medical/biochemical problems and begin to learn how to manage these problems and the patient himself. In keeping with our previously untested hypothesis, it was predicted that students would confront biases against the patient using CR more frequently when the opportunities to reflect were outside the formal assignments of the exercise itself.7 Such opportunities were provided not only beginning with the survey mentioned above, but also using extra-credit opportunities for teams of students to perform unprompted reflection and critical reflection on the difficulties and rewards of medicine, medical education and life.

It was also determined whether students’ empathy scores changed in association with their encounter with an incarcerated patient using the Jefferson Scale of Empathy.11,12 In general, scores on such surveys decrease (or remain unchanged) in students during health care professional training.6,13-15 Moreover, undergraduate paramedic students display less empathy toward substance abuse patients than toward patients with an intellectual disability, acute mental illness or who attempted suicide.16 Patients with substance abuse problems likely fair better, however, when healthcare professionals take their concerns seriously and remain nonjudgmental.17 Hence, exercises that raise students’ empathy scores through confronting their biases might also contribute to better patient care with fewer disparities. The main goals of our study were to determine whether students would confront their biases and raise their empathy scores in response to an incarcerated, African-American patient.

1

Strongly Disagree 2

Disagree

3 Somewhat Disagree

4 Neither

Agree/Disagree

5 Somewhat

Agree

6 Agree

7 Strongly

Agree

1. Having an encounter with a simulated patient in prison was very engaging

6.1 (0.9)

0 (0.0) 1 (0.5) 2 (1.0) 5 (2.6) 34 (17.6) 86 (44.6) 65 (33.7)

2. The encounter with a simulated patient in prison helped me realize how important understanding the basic sciences is to the practice of medicine.

4.6 (1.5) 3 (1.6) 23 (11.9) 15 (7.8) 47 (24.4) 51 (26.4) 36 (18.7) 18 (9.3)

3. The encounter with a simulated patient in prison caused me to consider and study possible causes of fatigue with more interest than likely would have occurred without that exercise.

4.7 (1.5)

2 (1.0) 20 (10.4) 11 (5.7) 49 (25.4) 47 (24.4) 44 (22.8) 20 (10.4)

4. The exercise with the simulated patient in prison will help me to be engaged with patients regardless of the setting or disposition of the patient.

5.8 (1.1)

0 (0.0) 4 (2.1) 2 (1.0) 14 (7.3) 37 (19.2) 81 (42.0) 55 (28.5)

5. The exercise with the simulated patient in prison helped me to see my potential biases toward patients more clearly regardless of the setting.

5.5 (1.3)

2 (1.0) 8 (4.2) 4 (2.1) 14 (7.3) 54 (28.0) 62 (32.3) 48 (25.0)

6. What biases of your own did you become aware of while watching the simulation of an incarcerated patient?

(See text for summary of qualitative responses) Table 1: Survey Regarding an Incarcerated Patient with Fatigue. Using the scale, students in the class of 2015 indicated the extent to which they agreed or disagreed with each of the statements above (193 [94%] of 205 students responded to questions 1-4 and 192 [94%] responded to question 5). Mean (and standard deviation) responses are shown to the right, and the number (% ) of students choosing a response are shown below each statement. Each mean is significantly different from neutrality; i.e., 4.00 (p<0.0001).


Methods Participants and Instruments Two hundred five first-year osteopathic medical students of Biochemistry at Midwestern University (Downers Grove, Illinois, USA) participated in the study. Their average age was 24 years (range 21-38 years) and 47% were female. The proportions of Caucasian, Asian, Black, Hispanic and other students in the class were 70, 23, 1, 1 and 4%, respectively. Students were invited to complete the 20-item Jefferson Scale of Empathy (JSE, S-Version for medical students) on the following five occasions; (1) first day of class in August 2011, (2) following the first of three biochemistry courses in September 2011, (3) three days after meeting the simulated patient described below in October 2011, (4) at the end of our second course in November 2011 and (5) at the end of our third course in February 2012.11,12 Evidence has shown the JSE to be a valid and reliable measure of empathy in medical students and physicians in the context of healthcare.12,13,18-21 The scale contains 20 items answered on a seven-point Likert scale from strongly agree (7) to strongly disagree (1). Students also completed a survey of their attitudes toward a simulated patient in prison (Table 1) three days after meeting the patient in October 2011. The students were then given an exercise on the patient to complete with their teams over the subsequent three days. Teams of 6-7 students each had been formed on the first day of class. Educational experiences and other attributes were distributed as equally as possible across the 30 teams. Study Design One faculty member (LR), is an African American Internal Medicine physician who has worked regularly with incarcerated patients. He played a simulated patient in prison during a 50-min introductory session to a workshop on a biochemical cause of fatigue (i.e., development of hemolytic anemia secondary to administration of an oxidant drug to a patient with a glucose-6-phosphate dehydrogenase [G6PD] deficiency). The patient portrayed by LR was the grandson of Henrietta Lacks. Students were expected to see the connection between this patient and a book they had read for their biochemistry courses entitled “The Immortal Life of Henrietta Lacks”.22 Students were required to read this book shortly after matriculating at Midwestern University in August 2011. Thus, students knew a great deal about the patient and his family before the workshop began in

October 2011. We expected this knowledge of the patient’s family history to help students confront their biases or otherwise perform critical reflection as part of a formal assignment (see below). Another faculty member (CR), is also a practicing Family physician. He facilitated a volunteer student’s interview of the patient in this initial session with the entire class present, observing and occasionally contributing to the interview. Three days later, students were given the two surveys described above and a team exercise to complete. The surveys were completed that same day, while students were given three more days to complete the team exercise. The exercise included predominantly clinical biochemistry data to interpret, and it included opportunities to reflect on and discuss the possible underlying causes of the patient’s fatigue. In addition, students were asked in the formal assignment to consider the importance of the richness of their knowledge of the patient’s family history. This richness included the knowledge that the patient’s grandmother was known to have an A variant of G6PD. In the 1960s, this variant was used to show that numerous cultured cell lines were HeLa cell contaminants.22 (The complete exercise is available on request from LJV.) Students also had regular extra-credit opportunities to reflect on, and discuss with their teams, topics of their choice concerning difficult issues in medicine, medical education and life.6-10 No additional prompts were given to students for these extra-credit opportunities. We did not want a prompt to elicit critical reflection (CR) but, rather, we wanted the CR to come from the students themselves. The extra-credit and other assignments were assessed for the presence of CR which is defined and contrasted with reflection (R) as follows;7

“When students reflect, they think about an issue and critique behavior. They may even refer to clichés on how best to behave. If they do not think about how they might improve their own behavior, however, then the R is not, by our definition, CR. In CR, students turn their thoughts and critique back onto themselves, see their own behavior as incongruent with their humanistic and professional values, and describe concrete ways better to align their behavior with their values.”

Using these definitions, written reflections were assessed for R and CR by two independent investigators (LJV and SLS). Grades were based on the amount of CR displayed by teams and their


members. The independently-determined grades for the assignments correlated well, and the correlation was statistically significant (r = 0.92, p<0.0001). Statistical Analysis Calculation of Pearson’s correlation coefficient (r) and other statistical analyses were performed using GraphPad Prism 5 Software, Inc. (LaJolla, CA). Jefferson Scale of Empathy scores were compared statistically using analysis of variance in association with the Tukey multiple comparison test. Whether students’ mean survey opinions, about their encounter with a simulated patient in prison, differed significantly from neutral was determined using a one sample t-test. Contingency tables of data, to test whether the frequency of CR varied for different reflection contexts, were assessed using either Fisher’s exact test or Chi square (X2) after Yates correction (when effect size was to be calculated). Effect size (ES) values were calculated from corrected X2 values (ES2 = X2/N) as described elsewhere.23,24 This study was reviewed and found to fulfill the criteria for exemption by the Midwestern University Institutional Review Board.

Results Quantifying individual students’ attitudes about their biases against the patient Students were invited to answer six survey questions regarding their encounter with an incarcerated patient (Table 1). Eighty five percent of students agreed that the encounter with a simulated patient in prison helped them see their potential biases more clearly while only seven percent disagreed (item 5, Table 1). Similarly, 90% of students said the exercise would help them to be engaged with patients regardless of the setting or patient’s disposition (item 4, Table 1), and 96% agreed that the encounter was engaging to them (item 1, Table 1). Students were less inclined to agree that the simulated patient encounter would cause them to consider and study possible causes of fatigue with more interest (item 3, Table 1). Nevertheless, 58% of them agreed with this statement, while only 17% disagreed. Similarly, 54% of students agreed that the encounter with the simulated patient helped them to realize the importance of the basic sciences to the practice of medicine (item 2, Table 1), while only 21% disagreed (perhaps because they already believed that the basic sciences are important). Ninety students also wrote answers to the last question in Table 1 concerning “what biases of your own did you become aware of…” while watching the

simulated interview of an incarcerated patient? Based on their responses to item 5 in Table 1, these 90 students were indistinguishable from those who did not write comments (i.e., 84% of the 90 students agreed that the encounter with the patient in prison helped them see their biases while 8% were neutral and 8 % disagreed vs. 85, 7, and 7%, respectively, for all 192 students). Seventy one students commented that they became more aware of racial, socioeconomic or other prejudices including prejudices against inmates. Some of the students’ quotes included;

Student 1: Before [the] patient entered, I assumed he would be African-American. That was wrong of me to do – very judgmental, racist, and feeding into stereotypes.

Student 2: I realized that I was thinking of the patient in a negative manner and was blaming him for his being in prison, automatically assuming that he was rude and of bad character. This was a very eye-opening experience and it made me realize that I should leave all of my biases at the door and treat every patient as a human being, as I would like my own family to be treated. Student 3: The first thing I noticed when the patient walked in was his skin color. We have had all Caucasians thus far and I was distraught that the prison patient was in fact black. It was distracting and I felt we were discriminating and very stereotypical – it distracted me.

Student 4: I became aware of my bias that people who have committed violent crimes should not receive the same care as someone who has not hurt another human being. I have become aware of this bias and I am working to reconstruct my thinking to reflect my goal of treating all patients, regardless of their past, equally and providing the best care to all patients.

Similarly, four more students recognized some level of bias in themselves as follows;

Student 72: Seeing the actual human under the “prisoner” label. Student 73: I had very specific notions of what went on in prison based on the hit TV show “Oz” and through popular culture. This was definitely altered by this exercise.


Student 74: I did not understand how prisoners got medical care. Student 75: I found it very interesting and felt a lot of empathy and sympathy for incarcerated patients.

In addition, 11 students stated that they were not biased. For example;

Student 76: I’m a pretty open-minded person, and don’t tend to judge or stereotype individuals. It was a nice reinforcement to see attention being given to patients in prison. Student 77: Because of the previous biochem reflections, I no longer have any biases. I find these reflections excessive and unwarranted…I believe that the students chuckled in the presentation due to this very worn out example of “Mr. Carter”/HELA…

Finally, four students commented only more generally that the presentation was “great”, “outstanding” or “very engaging”, while one student commented more generally that “simulated patients are unnecessary in biochem”. Confronting biases against the patient as teams within and outside the formal assignment Student teams had three days to answer a number of questions concerning the Biochemical cause of the patient’s fatigue and the management of his case. One of these questions was the following;

“How does knowing some of the richness of the patient’s family history influence his management as a patient?”

This question was designed to be consistent with the following quote at the beginning of the book containing the patient’s family history (with which students were familiar);

“We must not see any person as an abstraction. Instead, we must see in every person a universe with its own secrets, with its own treasures, with its own sources of anguish, and with some measure of triumph.” – Elie Wiesel (Nobel Laureate and Holocaust survivor)

We hoped that this question would elicit any otherwise unprompted CR by students regardless of whether the CR directly involved their biases against the patient. Nevertheless, no team performed CR in answering the above question, and

three of the 30 teams even argued that they should not give the patient preferential treatment in relation to other patients whose histories they knew less well. Teams overlooked the value in knowing as much family history as possible about all patients. Conversely, they could have reflected more deeply about their concern that they might be tempted to give this patient preferential treatment. In contrast, teams selecting (without prompting) this patient presentation to discuss for an extra credit opportunity outside the formal assignment, used CR in discussing their biases against the patient on 15 of the 19 teams selecting the topic. This difference from the frequency of CR within the formal assignment, described above, was highly statistically significant (X2 = 21.95 after Yates correction, p<0.0001 for CR on the extra credit vs. the formal assignment by these 19 teams). These CRs included the following;

Student on team 1: “…After witnessing the clinical case with Mr. Carter, I was taken back to our [previous] discussion in biochemistry about biases. During that discussion we spoke about how we would attempt to treat all patients, as we would like to be treated with no prejudices or judgments…However, we didn’t realize how we would react until we experienced the clinical case with Mr. Carter. As I gained more background information…I realized that I began to assume rather than wait to be told...by Mr. Carter…I felt very angry at myself for doing what I said I would not do in that kind of situation. Additionally, I realized that I had to really make a conscious effort to not make judgments…”

Teams selecting this patient encounter as their extra credit topic also performed CR more frequently than did the other nine teams electing to have this extra credit discussion on another unprompted topic of their choice (p=0.03, Fisher’s exact test). A lasting effect on an item of the Jefferson Empathy Scale The Jefferson Scale of Physician Empathy is a content-specific and context relevant instrument to measure cognitive empathy in health care professions students and practitioners.12 Student scores on the Jefferson Empathy Scale remained statistically unchanged across our three courses from August 2011 through February 2012, although the mean score increased somewhat between August and September and then declined to the August level between November and February (data not shown). However, when changes in scores on


individual items of the 20-item survey were assessed from one month to another, while at the same time comparing scores on different items to each other using ANOVA, the only change that stood out as statistically significant was in item 7. This reverse scored item reads;

“Attention to patients’ emotions is not important in history taking”11,12

This item is the only one of 20 on the Jefferson Empathy Scale that explicitly mentions history. When it was normalized to each student’s total score, a statistically significant increase in the item score occurred in association with the workshop on the incarcerated patient in October (p<0.01). The increase was sustained at least until the end of the Biochemistry courses in February 2012 (Figure 1).

Discussion By regularly confronting their biases, medical students should become better able to mitigate them and, thus, deliver patient care with fewer health care disparities.1 In response to the simulated encounter with an incarcerated patient with fatigue, most students did, indeed, seem to confront their biases. For example, 85% of students agreed that the encounter with a simulated patient in prison helped them to see their potential biases against patients more clearly, whereas only seven percent of students disagreed (item 5, Table 1). The vast majority of students’ written responses also support this conclusion (about 73 of 86 = 85% of pertinent written comments, see results). In these written comments, most students also had begun their own CR. Dissonance often leading to CR7 was most apparent among all of the 71 students explicitly stating that they had become more aware of their biases against the incarcerated, African-American patient during their encounter with him. Similarly, at least two of the four students recognizing some level of bias (see results) likely had experienced dissonance and begun CR. In addition, first-year medical student teams exhibited CR on their biases against the patient much more frequently in unprompted extra-credit exercises outside the formal assignment, than CR for any purpose within the assignment itself. The effect size (ES) for this difference is of crucial practical importance (ES = 0.75).23,24 An ES of 0.75 is statistically equivalent to reducing the death rate from 87.5% under control conditions to 12.5% under experimental conditions.24 This observation supports our previously untested hypothesis that it

is important to give student teams less structured assignments in which they can discuss whatever moves them, if more CR and, in the present case, confronting biases, are the desired ends.7 The exercise with a simulated patient in prison also had an effect on students’ scores for one item of the Jefferson Empathy scale. This effect in association with the exercise in October appeared to last through the following February (Figure 1). While we hope our efforts promote higher overall scores on such instruments, these improvements are not always sustained.9 Hence, it is somewhat encouraging that a statistically significant improvement was sustained on one item for several months. In this regard, the case exercise emphasized the patient’s history. Moreover, the improved item in this study (item 7 on the Jefferson Empathy scale) is the only one of 20 items that explicitly mentions history as an aspect of the patient’s information. Thus, perhaps improvements in such scales can be made on an item by item basis. We and others have reported partial improvements in one or some of the components of such instruments, while other components do not change or change in the opposite direction.10,25

Item 7 Scores Relative to Total Scores(Jefferson Scale of Empathy)

Aug

Sep

tOct

Nov

Feb

0.050

0.052

0.054

0.056

Month of Survey Administration

Mean (

+/-

SE

)

Item

7 S

core

/Tota

l S

core

Figure 1: First-year medical students scores on item 7 of the Jefferson Scale of Empathy increased significantly (p<0.01) in October 2011 in association with an exercise concerning an incarcerated patient with fatigue. The increase was sustained through February 2012 (p<0.05). Response rates to the survey from August through February were 94, 96, 94, 81 and 65%, respectively, out of 205 students.


Limitations The present study included one class of first-year medical students at a single institution. Therefore, the results should be generalized with caution. Furthermore, the findings may pertain to the particular experiences and exercises used, rather than to a broader set of possible contexts and assignments with similar intent. While the biases exhibited may be particular to our institution and similar US medical schools, however, we think parallel exercises could likely be designed for biases against patients by students in other countries. Finally, the study design did not include a randomly-assigned control group. For the results on the Jefferson Scale of Empathy, however, a baseline of scores was established for the two months preceding the experience with an incarcerated patient (Figure 1). Moreover, even if a control group displayed more CR on unprompted topics of their choices than on formally assigned exercises, our conclusion would be the same concerning the importance of such opportunities to reflect outside formal assignments.

Conclusions Unmitigated biases against patients contribute to health care disparities.1 For this reason, faculty led first-year medical students to examine their biases against an incarcerated, African-American patient. In response, most students began to confront their biases using CR. It was also demonstrated that learning teams of students are significantly more likely to examine whether their thoughts and behaviors are consistent with their values when they are given unprompted opportunities to reflect on such issues outside of more specific, formal assignments. In fact, the latter finding is of crucial practical importance for eliciting CR, at least within the context of the present study (ES = 0.75).23,24

Conflict of Interest We have no conflict of interest or commercial interest to disclose.

Keywords Basic sciences, biases, critical reflection, empathy, health care disparities

Notes on Contributors LON J. VAN WINKLE, PhD, is Professor and Chair of Biochemistry, Department of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA. SOPHIE LA SALLE, PhD, is an Assistant Professor of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA. LENDELL RICHARDSON, MD, is an Assistant Professor and Medical Director, Physician Assistant Program, College of Health Sciences, Midwestern University, Downers Grove, IL, USA. BRYAN C. BJORK, PhD, is an Assistant Professor of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA. PAULETTE BURDICK is an Administrative Coordinator, Biochemistry Department, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA. NALINI CHANDAR, PhD, is Professor of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA. JACALYN M. GREEN, PhD, is an Associate Professor of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA. SEAN M. LYNCH, PhD, is Professor of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA. CHESTER ROBSON, DO, is Clinical Affiliate Faculty and Assistant Professor of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois, USA. SUSAN M. VISELLI, PhD, is Professor of Biochemistry, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA.

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unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. Am J Public Health. 2012;102:945-952.

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3. Smedley BD, Stith AY, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in healthcare. Washington, DC: National Academies Press; 2003.

4. Dovidio JF, Penner LA, Albrecht TL, Norton WE, Gaertner SL, Shelton JN. Disparities and distrust: the implications of psychological processes for understanding racial disparities in health and health care. Soc Sci Med. 2008;67:478-486.

5. Rhoads KF, Cullen J, Ngo JV, Wren SM. Racial and ethnic differences in lymph node examination after colon cancer resection do not completely explain disparities in mortality. Cancer. 2012;118:469-477.

6. Van Winkle LJ, Chandar N, Green JM, Lynch SM, Viselli SM, Burdick P. Does critical reflection by biochemistry learning teams foster patient-centered beliefs among medical students? Med Sci Educator. 2011;21:158-168.

7. Van Winkle LJ, Robson C, Chandar N, Green JM, Viselli SM, Donovan K. Use of poems written by physicians to elicit critical reflection by students in a medical biochemistry course. Journal for Learning Through the Arts. 2011;7(1). Retrieved from: http://escholarship.org/uc/item/7513c5mv.

8. Van Winkle L, Dobie S, Ross V, Sharma U, Green J, Lynch S. Acute intervention to foster reflection on reciprocity in relationships increased participants’ patient-or student-centered orientation scores in association with a medical biochemistry course. Internet J Med Educ. 2011;1(2). DOI: 10.5580/11e6.

9. Van Winkle LJ, Fjortoft N, Hojat M. Impact of a workshop about aging on the empathy scores of pharmacy and medical students. Am J Pharm Educ. 2012;76:9.

10. Van Winkle L, Bjork BC, Chandar N, Cornell S, Fjortoft N, Green JM, et al. Improvement in pharmacy and medical student physician-pharmacist collaboration scores following a workshop to foster mutual understanding. Am J Pharm Educ. 2012;76:150.

11. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86:359-364.

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13. Hojat M. Empathy in patient care: antecedents, development, measurement, and outcomes. New York: Springer Verlag; 2007.

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ORIGINAL RESEARCH

The Introduction of Nutrition Education into the Medical School Curriculum: Using an Elective

Course to Teach Students the Fundamentals, the Science, and the Clinical Implications of Food

Nupur Agrawal, Sara A. Ostrosky & David Henzi University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

Abstract In an effort to address the lack of formal nutrition education at the University of Texas Health Science Center School of Medicine at San Antonio, two second year medical students with training in nutritional sciences and public health designed an elective course in 2011 to teach other medical students about fundamental concepts in nutrition. The course consisted of five interactive classes during which students participated in lectures and discussions. A total of 30 medical students completed the course during the 2011-2012 academic school year; they provided feedback through voluntary completion of surveys. Based on the data collected, 70% of students stated that they learned new information from the course, and 100% of students would recommend the class to peers. While students reported benefiting most from the interactive aspects of the course such as potluck dinners and group discussions, 75% also suggested that future courses should be based more on scientific evidence.

Introduction Chronic nutrition-related diseases, including diabetes and obesity, are rapidly becoming leading causes of morbidity and mortality in the United States.1 The increasing prevalence and the complexities associated with long-term medical management of these diseases require that physicians develop their understanding of nutrition and its impact on patients’ health.2 The first recommendation for introducing formal nutrition education into American medical schools was made in 1963 by the American Medical Association Council on Food and Nutrition.3 In 1985, the National Academy of Sciences declared that the amount of nutrition education in medical schools continued to be inadequate and, consequently, established the first specific nutrition guidelines for medical schools, which included a requirement of at least 25 hours of formal nutrition education.3 Since then, the Liaison Committee on Medical Education (LCME) has added nutrition as

one of the 34 competencies in behavioral and socioeconomic subjects required in the medical school curriculum.4 In addition, the National Board of Medical Examiners (NBME) continues to test medical students on nutrition management and treatment on the United States Medical Licensing Examination Step 1 and 2 exams.5 Despite these standardized requirements and the numerous resources that are available for furthering nutrition education, few undergraduate medical programs have successfully developed comprehensive nutrition education programs.6,7 As of 2009, only 25% of medical schools have a formal nutrition course, and on average, medical students receive only 19.6 hours of nutrition education during their entire undergraduate medical education.8 Perhaps it is a result of these deficiencies that 48% of physicians practicing internal medicine, family medicine, and psychiatry feel inadequate to prescribe nutrition-related advice and weight loss regimens to their patients.9 Currently, the University of Texas Health Science Center School of Medicine at San Antonio, hereafter referred to as UTHSCSA, does not have a formalized

Corresponding authors: Nupur Agrawal, 7210 Washita Way, San Antonio, Texas 78256, USA. Tel: +1 210 861-9497, Email: [email protected], and Sara Ostrosky, 4119 Medical Drive, Apt. C307, San Antonio, Texas 78229, USA. Tel: +1 281 794-1017, Email: [email protected]


nutrition course for medical students. First and second year medical students do receive some education in nutrition-related topics through the biochemistry, pathology, and pathophysiology courses. However, each lecture is delivered by a different instructor, so certain aspects of nutrition are taught repeatedly while others are completely disregarded. In an effort to address this lack of formal nutrition education, an elective has been created by student instructors to teach other medical students fundamental concepts in nutrition and public health.

Methods Two second year medical students, one with a Bachelor of Science in Nutritional Sciences and the other with a Master of Public Health degree, combined their interests and knowledge during the summer of 2011 to design a nutrition elective for fellow medical students. These students, hereafter referred to as “course instructors”, identified gaps in the UTHSCSA curriculum by pinpointing topics not included in the first and second year syllabi. Course instructors also sought advice from medical school biochemistry faculty members while developing lectures on topics to be discussed in the course. The course was designed to accomplish five main goals: introduce students to fundamental concepts in nutrition, help create a link between basic science courses and prevalent nutritional issues, demonstrate how academicians translate research into current practices in nutrition, increase awareness of nutrition-related diseases, and develop critical thinking skills needed to solve nutrition-related public health problems. These goals were consistent with eight of UTHSCSA’s curricular objectives and competencies (Table 1, Appendix).10 An official syllabus outlining the course’s purpose, objectives, format, and schedule was submitted to the UTHSCSA Curriculum Committee for review; the course was subsequently approved to begin in Fall 2011. In terms of structure, the elective consists of ten contact hours divided into five classes. Content is presented to students using combinations of the following strategies: (1) guided discussion sessions, (2) instructor-taught lectures, (3) guest lectures led by nutrition professionals, and (4) student-led projects. While instructors select general topics that provide a comprehensive sampling of key nutrition topics, students are able to suggest specific topics of interests via a pre-course survey administered through email. These additional topics are

incorporated into the individual classes throughout the course. All classes are held in the evening from 6 pm to 8 pm and revolve around a potluck dinner for which students sign up to bring food and drinks. Each class has a unique structure (Table 2, Appendix). The first and fourth class sessions incorporate group discussions, which are 30 minute exercises that provide students with a forum to voice their existing understanding of topics related to those classes’ areas of focus. The last class is entirely student-led. In preparation, students spend time outside the elective working in small groups to research nutrition topics of interest to them, and during the last class, they present their findings and analyses to their peers as a final project. To register for the course, students respond to an email sent out by the Assistant Dean of the Office of Student Affairs. The course is capped at 30 students to maintain the intimate environment needed to facilitate the interactive sessions and group discussions. During the 2011-2012 academic year, the course was taught twice (Fall 2011 and Spring 2012), and a total of 30 medical students electively completed the course. [Of note, these students did not receive credit on their transcripts in accordance with UTHSCSA guidelines on new electives.] In an effort to monitor the success of various teaching strategies and to better understand the overall effectiveness of the course, surveys were administered for voluntary completion to all students. Post-course surveys were created via surveymonkey.com and administered to all students via email (Table 3, Appendix). Response rates ranged from 32% to 100% (Table 4, Appendix).

Results Based on data collected from surveys administered after each individual class (Figure 1), students preferred class formats that included discussions or had a guest speaker. Students stated they learned the most new information through guest speakers and by presenting their final projects to one another. Interestingly, students claimed to learn the least amount of new information from the first and third classes, which focused on their topics of interest. Data collected from the post-course survey (Figure 2) showed that approximately 70% of students learned new information throughout the entire course. However, only 45% of students felt that the course was taught at an appropriate level for medical students. The majority of students would


instead have preferred a course based more on scientific evidence and including more discussion. Still 100% of students stated they would recommend the nutrition elective to their peers not enrolled in the course.

Overall, 100% of students in the class favored having a two hour evening course revolving around a potluck dinner. The majority of students reported that the addition of nutrition professionals and the final class project positively enhanced their experience in the course.

Figure 1. Data Results from Individual Class Surveys

Figure 2. Data Results from Post-Course Survey

0

10

20

30

40

50

60

70

80

90

100

Class 1 Class 2 Class 3 Class 4 Class 5

Surv

ery r

esp

onden

ts a

nsw

erin

g a

ffir

mat

ivel

y (

%)

Class format Learned new information

0

10

20

30

40

50

60

70

80

90

100

Appreciated

evening class

Appreciated

dinner

Benefit from

class project

Benefit from

guest speaker

Learned new

information

Taught at

proper level

Surv

ey r

esp

onden

ts

answ

erin

g a

ffir

mat

ivel

y (

%)


Discussion Based on survey results, verbal feedback provided by students to instructors, and observations made by instructors during the course, four strategies emerged as highly successful in developing students’ understanding of core nutrition and public health concepts: potluck dinners, nutrition professionals as guest speakers, combining lecture and discussion activities, and final class projects. However, several challenges were difficult to address including engaging all students throughout the course, collecting data thoroughly, and using an evidence-based curriculum to design the course. Each of the aforementioned successes and challenges are discussed in detail. Potluck dinners In order to ensure that students had time to attend the course, the nutrition elective was centered around a potluck dinner. This opportunity for students to eat and learn at the same time made overall class attendance high at approximately 80%. Course instructors and students shared the responsibility for bringing utensils, food, and drinks for each class, and guest lecturers were invited to dinner as a thank you token with no responsibilities. An online spreadsheet used as a sign up sheet proved useful in preventing missing or duplicate items. As a result, each potluck was an organized dinner consisting of a range of dishes including appetizers, salads, pastas, casseroles, desserts, and nutritious snacks. Because the dishes at the potluck were home-cooked meals prepared by the students themselves, the dinner stimulated discussion on how to prepare healthier meals. Nutrition professionals as guest speakers Although the class was primarily instructor-led, the addition of faculty speakers allowed students to understand how nutrition concepts tie into cutting edge research and ultimately translate into more comprehensive patient care. The guest speakers, which included hospital dietitians, academic dietitians, and associate professors in nutritional sciences, successfully provided diverse perspectives on nutrition and offered students the opportunity to ask questions about nutrition topics beyond the course instructors’ scope of expertise. Combining lecture and discussion activities First and second year medical students are often in class from 8 am to 5 pm, which makes it difficult to attend courses outside regular school hours; however, students seemed interested in attending the 6 pm to 8 pm nutrition course because classes deviated from the traditional medical school lecture

format. Specifically, students enjoyed classes that combined discussions with lectures (Figure 1). Discussions revolved around specific topics, including medical manifestations of nutrition-related diseases and fad diets, which helped build a sturdy foundation for the lectures that followed. To facilitate participation from all students, instructors circulated a jar of short but thought-provoking statements (Table 5, Appendix) around which students built a multi-faceted conversation. During these particular discussions, the desks and chairs in the room were arranged in a circle, so all students faced each other. Then, going around the circle one at a time, each student (1) read the selected statement, (2) orally reflected upon its meaning and significance, and (3) posed questions or thoughts that encouraged other students to generate a discussion on the statement. This process was repeated until everyone in the circle participated, and it facilitated a thorough exploration of the complex and multi-dimensional nature of topics in nutrition. Final class projects At the end of the course, students were required to explore in depth a nutrition topic of interest to them and to share their findings with other students in the elective. Students were encouraged to incorporate the knowledge and critical thinking strategies taught in the course to create their final presentations. Presentation topics included establishing a farmer’s market at UTHSCSA, living on the Supplemental Nutrition Assistance Program, and understanding fourth graders’ perceptions of food. Students successfully communicated reasons why nutrition education is important and how fundamental nutrition concepts will better inform their medical decisions as future physicians. Engaging all students Based on informal conversations with students, instructors gauged that most students registered for the course with one of two primary goals: (1) to build a foundation of basic nutrition and public health principles or (2) to supplement their existing knowledge of these subjects. Students falling into the first category realized the importance of having nutrition education as part of their medical school training but did not have the background knowledge or resources to explore the subject independently. Students of the second category had either previously received formal training in nutrition or read extensively about nutrition on their own. This dichotomy made it difficult for instructors to design classes that simultaneously addressed the needs of both groups. Instructors combined both general concepts that would appeal to the first group of


students with more specific topics in nutrition that would appeal to the second group. Although this format helped build a common foundation for all students in the course, it caused some students in the second group to not learn as much new information as their peers in the first group. In the future, this issue can be addressed by conducting a pre-course assessment of students’ existing knowledge base, so the course can be shaped to engage the majority of students longitudinally as the course progresses. Data collection Because students were requested to complete the various surveys on a voluntary basis, student response varied widely, ranging from 32% to 100% (Table 4, Appendix). This made it difficult to develop a representative understanding of students’ perspectives on the course. An attempt was made to remedy this problem through a comprehensive post-course survey that was administered on paper immediately after the last class. Another issue was that survey questions focused primarily on students’ attitudes and perceptions of course structure and content; future surveys should aim to include an assessment component with knowledge questions that truly assess the mastery of fundamental concepts in nutrition and public health. If the questions are designed carefully, perhaps with input from faculty members with a background in nutrition, the results of the assessment will be indicative of course outcomes, which are important in driving the long-term educational process. Using evidence-based teaching strategies to design the course Because there was no existing nutrition curriculum at UTHSCSA, the nutrition elective was designed primarily considering the course instructors’ expertise and the course students’ expressed interests. While this approach was beneficial in discussing popular topics, it did present a challenge in terms of appropriately balancing time between topics deemed “interesting” and topics essential to building a strong foundation in learning about nutrition. As the elective evolves in its depth and comprehensiveness, instructors are encouraged to continue using the aforementioned successful strategies to stimulate discussion amongst the students, but they should lead the teaching sessions based on established curricula, such as those outlined by the LCME and NBME, in order to help students learn key concepts regarded by experts as foundational.

Recommendations and Conclusions Students participating in the course reported that, through the nutrition elective taught at UTHSCSA in Fall 2011 and Spring 2012, they were able to increase their understanding of fundamental concepts in nutrition and its role in medicine and public health. This success was attributed in large part to the evening time of the course, the potluck dinner format, the combination of discussion and lecture activities, and the incorporation of guest speakers. Given that students completed the course on a voluntary basis and that 100% of them would recommend the course to their peers, it is reasonable to conclude that the course provided a positive opportunity for medical students to learn more about nutrition. Although data showed that students favored a more evidence-based curriculum for the class, it was difficult for the instructors as full-time medical students to design such a comprehensive curriculum and then relay it to students in only ten hours of class time. Such goals can be met most feasibly through formalized incorporation into the medical school curriculum. If nutrition education ultimately becomes a formalized part of the medical school curriculum at UTHSCSA, past and present instructors of the nutrition elective will be available to the faculty and administrators designing the objectives to inform them of the successes and challenges encountered while teaching the elective. Whether or not the nutrition elective will continue to exist at that time will depend on students’ interest. The elective may transform into a forum for exploring advanced nutrition topics in depth, or it may be eliminated altogether. However, no discussions are being held at UTHSCSA at this time that would suggest such formalization in the near future. Therefore, the nutrition elective will be maintained by medical students to facilitate learning and exploration of fundamental concepts in nutrition and public health. Course instructors from the 2011-2012 school year identified three student leaders to continue the elective and serve as course instructors during the 2012-2013 academic session; two of the new instructors have a Bachelor of Science in Nutritional Sciences, and the third instructor taught nutrition in public schools before coming to medical school. As of January 2013, a total of 70 students have successfully completed the nutrition course. To future course instructors and others looking to spearhead similar courses, we highly recommend (1) planning the course to fit student needs (including a potluck dinner, discussion sessions, and class


projects that encourage self-study), (2) surveying students in advance to determine their existing knowledge of nutrition and public health, and (3) using more aggressive data collection tools to pinpoint successes and areas for future improvement.

Notes on Contributors NUPUR AGRAWAL1, MPH, CPH, is a MD candidate (degree expected May 2014) at the University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA. SARA A. OSTROSKY1, BS, is a MD candidate (degree expected May 2014) at the University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA. DAVID L. HENZI, EdD, is Assistant Dean of the Office of Student Affairs and an Assistant Professor in the Department of Ophthalmology at the University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA. 1These authors contributed equally to this paper.

Keywords Applied, Predictive, Diagnostic, Simple, Inexpensive

References 1. Bantle, JP, Wylie-Rosett, J, Albright, AL,

Apovian, CM, Clark, NG, Franz, MJ, Hoogwerf, BJ, Lichtenstein, AH, Mayer-Davis, E, Mooradian, AD, Wheeler, ML. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association Diabetes Care. 2008; 31(Suppl 1):S61–78.

2. Vitolins, MZ, Crandall, S, Miller, D, Eddie, I, Marion, G, Spangler, JG. Obesity educational interventions in U.S. medical schools: a systematic review and identified gaps Teach Learn Med. 2012; 24(3):267-72.

3. Committee on Nutrition in Medical Education, Food and Nutrition Board, National Research Council. Nutrition education in U.S. medical schools National Academy Press. 1985.

4. LCME Connections Educational Program for the MD Degree (ED). http://www.lcme.org/connections/connections-2012-2013/ED-10_2012-2013.htm [Accessed January 5, 2013]

5. Hark, LA, Iwamoto, C, Melnick, DE, Young, EA, Morgan, SL, Kishner, R, Hensrud, DD. Nutrition coverage on medical licensing examinations in the United States Am J Clin Nutr. 1997;65(2):568-71.

6. Nutrition Academic Award National Site at the National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/funding/training/naa/index.htm [Accessed August 19, 2012]

7. Nutrition in Medicine. http://www. nutritioninmedicine.net/ [Accessed August 19, 2012]

8. Adams, KM, Kohlmeier, M, Zeisel, SH. Nutrition education in U.S. medical schools: latest update of a national survey Acad Med. 2010;85(9):1537-42.

9. Jay, M, Gillespie, C, Ark, T, Richter, R, McMckern, M, Zabar, S, Paik, S, Messito, MJ, Lee, J, Katlet, A. Do internist, pediatricians, and psychiatrists feel competent in obesity care? J Gen Intern Med. 2008; 23(7):1066-70.

10. UT Health Science Center School of Medicine Curricular Objectives and Competencies of the Educational Program for the M.D. degree. http://som.uthscsa.edu/ume/objectives.asp [Accessed January 6, 2013]


APPENDIX

1.3 Demonstrate respect for human dignity.

1.6 Demonstrate appropriate patient advocacy.

2.1 Demonstrate knowledge of normal structure and function of the human body.

2.3 Demonstrate knowledge of the clinical manifestations of common conditions and disorders.

2.5 Understand the basic principles of clinical and translational research.

2.6 Understand the epidemiology of common conditions and disorders.

3.7 Construct appropriate management strategies for common conditions and disorders.

3.10 Demonstrate the ability and commitment to continuously improve medical knowledge and skills. Table 1: UTHSCSA Medical School Curricular Objectives and Competencies Fulfilled by Elective course10

Class Class Topic Instructor Discussion Topic Topics of Students’ Interest

1 Introduction to Fundamental

Concepts in Nutrition

Course

Instructors

General Concepts and

Perspectives on

Nutrition

Fad Diets

Vegetarian Diet

Vegan Diet

2 Translating Nutrition

Research into Clinical

Practice

Guest

Speaker

None None

3 Biochemistry from the

Nutrition Perspective

Course

Instructors

None Exercise and Nutrition

Calorie Restriction

Vitamins

Caffeine and Diet

4 Obesity: Addressing

Nutrition-Related Diseases

Course

Instructors

Recognizing and

Approaching Patients

with Eating Disorders

None

5 Applying Nutritional

Practices to Devising Public

Health Solutions

Peer-to-Peer

Instruction

None None

Table 2: Structure of Individual Classes

Figure Survey question Instructor Interpretation

Please rank the following on a scale from 1 through 5.

1- Disagree

2- Moderately disagree

3- Neutral

4- Moderately agree

5- Agree

Students answering 4 and 5

answered affirmatively.

1 Did you enjoy the format of today’s course? Please rank your answering of the above scale.

1 Did you learn new information in today’s course? Please rank your answer on the above scale.

2 Did you appreciate having the course in the evening? Please rank your answer on the above scale.

2 Did you appreciate having a dinner with the course? Please rank your answer on the above scale. Table 3: Examples of Survey Questions


Class Number Student Responses Class Attendance % Response Rate

1 25 30 83%

2 20 27 74%

3 7 19 37%

4 6 19 32%

5 30 30 100%

Post-Course Survey 30 --- 100%

Table 4: Student Response Rate by Class

Class Discussion Topic Examples of Discussion Statements

1 General Concepts and

Perspectives in Nutrition

“Sickness is felt, but health not at all.”- Thomas Fuller, M.D.

I eat Subway every day, but I always choose the healthy 9-grain

wheat bread.

The first thing I look at on a nutrition label is the calorie count.

4 Recognizing and Approaching

Patients with Eating Disorders

I have been on the Jenny Craig diet for the past year.

I follow the South Beach diet.

Every time I look in the mirror, I feel fat. I suffer from anorexia.

Table 5: Examples of Discussion Activities




ORIGINAL RESEARCH

Cultural Competency in the Medical Genetics Classroom: A Case Study for a Diverse Learning

Community

Shoumita Dasgupta Boston University School of Medicine, Boston, MA, USA

Abstract Medical educators have embraced the commitment to teach and support their diverse learning community as an integral facet of their educational philosophy. This study explores application of this principle to a first-year medical genetics small group exercise. The author developed and implemented a case study exploring sickle cell disease and ancestry-based genetic predispositions in the Boston University School of Medicine Medical Genetics course. Because the small group composition itself deliberately maximized student diversity, it was an ideal setting to tap into the wide range of student experience. The author measured knowledge gain, using a pre- and post-test model, and student engagement through course evaluations. Pairing case-based discussion and diverse student groups created an engaging curricular exercise designed to explore clinical issues related to diversity. Implementation of the case demonstrated significant knowledge gains on genetic concepts specifically related to genetic predispositions and testing strategies that are influenced by a patient’s ancestry. Students reported especially strong motivation to understand issues of clinical importance in the case. Because many medical school courses utilize small group teaching, tailoring these strategies, as described in this study, would help to strengthen an institution’s commitment to diversity by blending learning in cultural competency and medical science.

Introduction Training a diverse pool of medical students is widely recognized as a critical first step towards reducing, and eventually eliminating, health care disparities.1,2 Towards this end, many medical schools nationally have worked to develop curricula focused on cultural competence. Initially, curricular efforts in the area of cultural competence focused on communication between the physician and patient, but they have evolved to include education designed to increase health care providers’ awareness of health care disparities and the effect of race and ethnicity on clinical decision-making. 3 Cultural competency curricula tend to use case discussions to highlight the role of cultural background and beliefs in a clinical setting, to explore complementary and alternative medicine,

and to study other cross-cultural issues. These curricula are often placed in the early portion of the clinical curriculum.4-6 As such, they are typically not integrated into the basic science curriculum, but are instead focused on elements of the cases that do not require pre-existing clinical or scientific knowledge. In the absence of a scientific discussion of the complex relationship between genetics and ancestry, we face the danger of focusing these conversations on stereotyped attitudes and behaviors, essentially propagating distorted racial profiles.3 Furthermore, by not integrating a scientific approach to cultural competency into the major efforts to teach medical knowledge and skills, we risk marginalizing this critical component of medical education. By placing cultural competency learning objectives in the context of medical students’ scientific education, we can begin to move away from subjective oversimplification of this complex issue. Redirecting efforts toward a more evidence-based treatment of the topic may ultimately contribute to reducing healthcare disparities.

Corresponding author: Dr. Shoumita Dasgupta, Department of Medicine, Biomedical Genetics Section, Boston University School of Medicine 72 E. Concord Street, L-317H, Boston, MA 02118 USA; Tel: +1 617-414-1580; Fax: +1 617-414-1646; email: [email protected]


Human Genetic Variation and Health With the release of the initial sequence of the human genome and the subsequent studies examining human genetic variation around the world, there has been a revival of the debate on whether the basis for race is biological or cultural.7-

10 Some scientists have found that the vast majority of human genetic variation can be found within broadly-defined racial groups, and only a minority of this variation can be found between the groups.11 This observation suggests that race is more of a cultural construct than a biological one. Scientists have also found that genetic variation and ancestry tend to cluster in population categories that are geographically-based; furthermore, these classifications are only modestly similar to racial categorizations.12 This disconnect between race and genetic ancestry occurs because race only captures partial information on ancestry while also mixing in ethnic and societal variables. As such, race is not a proxy for genetic ancestry and is an imperfect predictor for presence of genetic risk factors. When this principle is misunderstood, it can lead to racially-based clinical decisions that do not take into account the patient’s individual risk factors; this type of misinformed clinical strategy can contribute to health care disparities. Exploration of the fundamental concepts defining the complex relationship between genetics, geographic ancestry, and race enriches our scientific understanding of cultural competency in health care. Furthermore, health disparities are expressed acutely within the field of genetics. For instance, minority-serving physicians are less likely to order genetic tests and refer patients to genetics health care providers than their majority-serving peers.13 In addition, minority patients themselves are less likely to know about the availability of genetic testing for their own disease risk profile.14 As such, these concepts related to cultural competency are well suited for inclusion in the basic science component of a medical school curricular structure under the umbrella of studies in genetics. Furthermore, because genetics is primarily taught in the first year of medical school, this creates an early educational opportunity to introduce these vital concepts and to combat health disparities.15 Cultural Competency and Genetics There have been some initial efforts towards including cultural competency as a component of genetics education. For example, the National Society of Genetic Counselors recently assembled a Genetic Counseling Cultural Competence Toolkit, which allows users to work through 9 cases exploring issues of cultural competence.16 In

addition, the Genetics in Primary Care initiative is a series of cases that were originally designed as a faculty development training program. The core curriculum was subsequently revised to include materials on cultural competency, and a framework for examining these issues was created to help guide the use of these cases.17,18 Notably, these efforts focus on clinicians, including physicians and genetic counselors, but an educational intervention for the early trainee with the goal of blending education in cultural competency and genetics has not yet been described in the literature. This manuscript describes a case designed for use with first-year medical students during the pre-clerkship phase of their education. This case focuses on sickle cell disease, in part because of its historical association with racial discrimination and as a vehicle to allow discussion of fundamental genetic concepts.19 This article highlights the elements of student group composition in maximizing diversity in the classroom. In addition, the impact of the implementation of this case in a diverse environment on learning outcomes and on student attitudes toward the case material is assessed.

Materials and Methods Diverse Participants and Small Group Composition First year students at Boston University School of Medicine are required to take a six-week course in Medical Genetics. The student body is composed of students who enter through the traditional pathway of entry (the 4-year MD pathway) as well as a number of specialized pathways of entry (Table 1a). In order to maximize diversity of the working groups and to mirror the pluralistic society in which they will be practicing medicine, the 175 students in the 2011 Medical Genetics course were organized into student groups that maximize diversity in terms of pathway of entry.20 The specialized pathways represent interdisciplinary programs of study, pathways conducted in partnership with undergraduate institutions with large populations of students who are ethnically underrepresented in medicine (the Early Medical School Selection Program, EMSSP), and accelerated curricula. In addition to diversity in terms of pathway of entry, demographics of student groups were measured in terms of a variety of additional measures of diversity.


Pathway of entry Number of

students Percentage of students

4-year MD (Post-MA 4-year MD*)

118 (23)

67.4% (13.1%)

MD / PhD* 5 2.9%

Early Medical School Selection Program (EMSSP)# ^ 14 8.0%

7-year BA-MD Program^ 27 15.4%

Modular Medical Integrated Curriculum (MMEDIC) ^ 10 5.7%

Modular Medical Integrated Curriculum (MMEDIC) / PhD^* 1 0.6%

TOTAL 175 100%

Table 1a: Demographic Profile, Medical Genetics, Graduating Class of 2014

Member Program Affiliation

1 Early Medical School Selection Program (EMSSP) #^

2 7-year BA-MD Program ^

3 Post-MA 4-year MD*

4 4-year MD

5 4-year MD

6 4-year MD

Table 1b: Example Medical Genetics Student Team * Operated in conjunction with graduate programs on medical campus of Boston University # Admissions pathway operated in partnership with 13 undergraduate institutions that have significant enrollment of students who are ethnically underrepresented in medicine. One half of the underrepresented students in the first year class are admitted through this mechanism. ^ Operated in conjunction with undergraduate campus of Boston University

Figure 1: Dimensions of Diversity in Student Groups Each student group was composed of 5-6 students, and the diversity of the membership of each group extended well beyond the pathway of entry for the students. The average number of students in each group demonstrating different aspects of diversity is summarized in this chart.

0 0.5 1 1.5 2 2.5 3 3.5 4

Number Female

Number Male

Number of Racial, Ethnic, or National Identities

Number of Pathways of Entry

Number of Languages Per Person

Number Underrepresented in Medicine

Average Number Per Student Group

Dimensions of Diversity in Student Groups


The student groups were composed of 5-6 students per team, and each team had, on average 3.7 different educational pathways represented by their student members. No two pathways were duplicated within a single team with the exception of students from the 4-year MD program. The most common group composition was three 4-year MD students, one Post-MA 4-year MD student, one Early Medical School Selection Program (EMSSP) student, and one 7-year BA/MD student (Table 1b). Furthermore, the student groups had, on average, at least one student from a background that is considered underrepresented in medicine (Figure 1) relative to their numbers in the general population.21 However, this is only one measure of the diversity of the student groups, since the average number of racial, ethnic, and national identities represented in each group was 3.6 in each group of 5-6 students (Figure 1). For example, a typical student group could contain a Cuban student, a Peruvian student, an African American Student, and 3 Caucasian students. Furthermore, the students spoke an average of 1.9 languages per person (Figure 1), with groups including students fluent in everything from English to Chinese, Hindi, Spanish, and Polish.

There were six break-out rooms with five teams meeting in each, for a total of 30 teams of students. The teams of students met during class time for active learning exercises, including the case described in this report. Discussion facilitators One discussion facilitator oversaw each of the six rooms. These discussion facilitators were selected from a pool of invited applicants because of their strong performance in the course during previous years and because of their status as senior medical students engaged in the clinical or research phases of their education. The author trained the facilitators during sessions that focused on teaching techniques, scientific content, and classroom dynamics. A facilitator guide for this session is available through the AAMC’s MedEdPORTAL.22 The facilitators were involved in leading two team-based sessions of two hours each: one that focuses on pedigree analysis and a second that focuses on sickle cell disease. Faculty are responsible for leading the other course sessions, including lectures and patient panels.

Box 1a: Flowchart of Sickle Cell Trait and Sickle Cell Disease: A Case Study (22).


Sickle Cell Trait and Sickle Cell Disease: A Case Study The sickle cell disease case discussion is carried out towards the end of the Medical Genetics course (Supplementary Content 1).22 It is placed late in the course in order to facilitate integration and application of concepts introduced in earlier sessions, including the coverage of disease prevalence in various ancestral groups and genetic testing strategies. The case study focuses on individuals from African American and European (Mediterranean) ancestral backgrounds, and a flowchart for the elements of the case discussion is included in Box 1a. This curricular structure is derived from the basic Team-Based Learning strategy, but with modifications designed for this particular case study and learning environment.23 Because the case involves integrating concepts from throughout the Medical Genetics course, students complete an individual readiness assignment prior to coming to class. This assignment takes the shape of an individual quiz administered on-line that focuses on the relationship between mini clinical vignettes and recommended genetic testing options. Once the students arrive in class and are seated in their groups, they engage in a group readiness assignment, a pre-test that focuses on three primary conceptual domains: ability to calculate genetic risks from a pedigree, ability to determine the best person in the kindred to initially test, and ability to recommend appropriate testing strategies. Notably, these three domains are assessed in the context of a clinical vignette detailing a complex family history including information on the ancestry of the patients. In particular, the testing strategies that are most appropriate within the given clinical vignettes are not the standard strategies, and the students are asked to integrate knowledge of ancestry into their risk assessment and proposed testing strategy. Without taking into consideration these variables, the students would risk recommending testing strategies that are not effective in the family structures and ancestral groups described and that would yield false negative results. The same three domains are tested after the case discussion using a post-test administered by the facilitators at the end of class. In addition, as the teams are taking the multiple choice pre- and post-test, they must agree on a particular answer choice before selecting it on an Immediate Feedback Assessment Technique answer sheet, so it truly encourages group participation. This type of answer sheet allows students to scratch off their answer choice on a lottery-style card and immediately see if their selected choice was correct.

Box 1b: Learning Objectives for Sickle Cell Trait and Sickle Cell Disease: A Case Study (22)

After the pre-test, students move from a more regimented exploration of the concepts to the open-ended case discussion. The learning objectives for the case are described in Box 1b and include elements of scientific knowledge as well as cultural competency in the context of genetics. Students are provided with discussion questions to guide them through the case itself, and a facilitator is circulating in each break-out room to ensure that every team is progressing through the case appropriately. Once the students reach the point of the case where they must hypothesize the genetic mechanism contributing to the clinical findings, a second part of the case is provided to the students to encourage further consideration of the concepts. After the teams complete the case, the discussion questions are reviewed by the students in the room by comparing answers across teams. Facilitators are responsible for supporting active discussion of these answers and for ensuring that students understand the underlying genetic concepts. After this phase of class, students wrap up by completing the post-test described above. The case (parts I and II), the discussion questions, and a facilitator guide are available through the AAMC’s MedEdPORTAL.22 Data Collection and Analysis Data were collected from the students through normal course activities, including pre- and post-test results and optional anonymous course evaluations. The methods of data collection have no expected risks or discomforts to the participants,

By the end of this case discussion, students should be able to:

1. Determine which genetic testing methods are most informative and most efficient in different clinical scenarios. Compare and contrast the use of molecular genetic testing and biochemical hemoglobin testing in establishing the diagnosis of sickle cell disease.

2. Assess the power and limitations of genetic testing as well as the necessity of testing family members’ DNA under certain circumstances.

3. Discuss the influence of compound heterozygosity on clinical outcome and management decisions.

4. Describe the social and ethical issues associated with a new diagnosis of sickle cell disease.

5. Explain issues of carrier testing for hemoglobinopathies as they relate to ethnic minority groups and minors.


and the IRB granted exempt approval for this protocol, number H-31198. Once the data were collected, gains between pre- and post-tests were assessed and their statistical significance was calculated using a students’ t-test. Student engagement with the material was assessed in the course evaluations via a directed question and free-text responses.

Results The first dimension analyzed was the potential for knowledge gains after engaging in the case discussion activity. Student performance in the small groups was very strong, with 29 of the 30 groups earning perfect scores on the post-test; the overall gain from pre- to post-test demonstrated statistical significance with a p-value of 1.5x10-6 (Figure 2a). The results were further analyzed to determine which content areas had the most significant improvement in scores, and, as expected from previous attention to this topic, the students arrived at the case discussion with a strong working

knowledge of how to make genetic probability calculations. The case exercise curriculum had a significant impact on the students’ ability to understand who in the family history should ideally be tested first and what type of test was most appropriate, with p-values of 1.1X10-10 and 3.2x10-14 respectively. These elements of the case study were both designed to reflect the importance of utilizing information about the geographic ancestry of the patients outlined in the vignettes. If this information was not properly integrated into the testing strategy, then the individuals in question might be tested by standard methods developed for other populations of patients. The result of an error of this type could be determination of a false negative result, where a patient is at risk for a particular condition, but the genetic testing strategy employed does not detect that risk factor. This type of error could ultimately contribute to the existence of health care disparities. As such, student mastery of this concept at the junction of basic science and cultural competence is directly related to providing quality healthcare to future patients.

Figure 2a: Pre- and Post-Test results by topic area The scores for each subject area were averaged across the student teams. Those pairs marked with * represent statistically significant gains. The p-values determined by students’ t-test were as follows: probability analysis (1.0), who to test (1.1X10-10), how to test (3.2x10-14), and overall (1.5x10-6).


Figure 2b: Student course evaluation results The course evaluation data (n=62) displayed demonstrates that students were motivated primarily to learn concepts of clinical importance.

Students also had the opportunity to provide feedback through anonymous course evaluations. The course evaluations were administered at the completion of the course, just after the case discussion. Students responded to a question about what features of the case most influenced their level of interest, and they reported that a motivation to learn concepts of clinical importance was the most attractive feature of the case (Figure 2b). List 1: Student course evaluation comments

“I would have liked to have more small group discussions and case discussions because those really reinforced the material.” “I think the pre-discussion quizzes were vital to group dynamics. It ensured that everyone was at least up to par in the material, and that everyone had something to add.” “I think the groups were chosen well, where those that really understood the material explained the concepts to those that didn't.” “The group learning experience is fantastic. I learn a lot from solving problems as a group and listening to valid points that teammates pointed out.” “I think it was great to put us in smaller groups within the discussion group. I found this format very helpful.” “In comparison to other class discussions, this [sickle cell disease case discussion] felt more like an actual discussion since the groups were so small and most of the time was spent discussing rather than sitting in on a smaller lecture.”

“The questions posed were complex, and this definitely encouraged discussion and debate more so than I have seen in other courses.” “I got a lot more out of the discussion by discussing the topics with my small group FIRST, then reviewing concepts as a large group.” “Because we knew we would be receiving answers immediately following the discussion, we were able to focus much more on logical application of concepts. This was greatly superior to concerning ourselves with the ‘right’ answer.”

In addition to the focused questions on the course evaluation, students also provided unstructured comments for feedback. The students commented on how the organization of the sessions and of their teams positively contributed to the experience for them (List 1). They appreciated the progression from individual readiness assignments to group assignments. The students also indicated that the assembly of small teams of students within the larger classroom section greatly facilitated their interactions. Importantly, these elements of educational design appear to have helped them to focus on the big picture of the “logical application of concepts” rather than “concerning [themselves] with the ‘right’ answer.” Furthermore, the successful implementation of this case also correlated with strong group dynamics, which, in the setting of highly diverse teams of students, directly supports the goal of cultural competency in the medical genetics classroom.

0% 10% 20% 30% 40% 50% 60% 70% 80%

interest in helping small group get through task

complex nature of the analysis

motivation to learn concepts important for exam

motivation to learn concepts of clinical importance

What feature(s) most influenced your level of interest in the Sickle Cell Disease case material?


Discussion The design of this case on sickle cell disease seeks to blend the often separate goals of training a culturally competent and scientifically knowledgeable physician workforce. The findings demonstrate that students gain knowledge of the genetic concepts introduced through the case while also participating in a diverse educational setting. The fact that their interest in clinically important information from the case outranked an interest to learn concepts important for the exam emphasizes the relative importance of this curricular element, even when compared to the traditionally valued multiple choice question banks. Because the students express engagement with the material at a level that reaches beyond what may be found explicitly on the exam, this suggests that participation in these types of activities helps students to recognize the value of delving deeper into clinically relevant concepts. Given the demographic shifts in society, national healthcare workforce shortages, and increasing evidence of existing health disparities, the fundamental importance of diversity and inclusion has become a medical education imperative. To

avoid creating training in this area that is based on cultural stereotypes, this case is designed to explore these concepts through a scientific lens. Traditionally, many medical educators design their pedagogy around the domains of knowledge, skills, and attitudes, giving equal weight to each element. This subdivision of objectives has been delineated for education in the realm of cultural competency as well.24,25 I propose viewing cultural competency as a core attitude and belief that should serve as a foundation for the detailed exploration of clinical knowledge and skills (Figure 3). With this paradigm shift, educators may integrate concepts of cultural competency throughout a medical curriculum. For instance, awareness of cultural competency issues will help students in their pre-clerkship years to understand why an individual with sickle cell trait may be concerned about the risk to future children

for both sickle cell anemia and -thalassemia, both conditions with significant genetic burdens in specific ancestries. In addition, they can appreciate why particular cancers may be more prevalent in certain ancestral groups and why genetic predisposition testing strategies may have to be modified for members of those groups.

Figure 3: Cultural Competency as a foundational principle upon which to build clinical knowledge and skills This framework models the foundational nature of cultural competency as a core value to support medical education objectives in clinical knowledge and skills.


Conclusions In order to make cultural competency an integral facet of medical education, it needs to be introduced early in the medical curriculum, rather than remain relegated to the clerkship years or the hidden curriculum. Because of the basic nature of the scientific aspects for this sickle cell disease case, it can be implemented early in the curriculum, to integrate this topic into the ongoing institutional conversation on diversity and inclusion. Operationally, implementation of this case is easily scaled up for large classes with involvement of a modest number of discussion facilitators; this is possible because of the peer education element that allows students to work within teams as part of this educational exercise. The peer education component itself is an invaluable element of this case design, as it allows students to develop effective habits for working in diverse teams, which will also ultimately help the students to relate to future patients from diverse backgrounds. Finally, this case emphasizes the fact that “every human being is genetically unique and so must be treated as an individual, not an example of a group defined by geography or race.”12 By introducing this critical concept into the medical genetics classroom and into their diverse team structures, we can convey to our trainees that we value an open, cross-cultural dialogue on this topic of fundamental importance to our medical education community.

Acknowledgements The author would like to express her deepest appreciation to the talented cadre of small group facilitators who have made implementation of this educational innovation possible. In particular, the author would like to extend thanks to Amelia Haas Baker, Ayodele Buraimoh M.D., Bimal Chaudhari M.D., Chad Farris, and Tim Hanley, and for their contributions towards improving this class session over the years. The author would like to also thank Dean Karen Antman, M.D. for her support of these small group initiatives and to Dr. Peter Cahn Ph.D. for his careful reading of the manuscript. The IRB granted exempt approval for this protocol, number H-31198.

Notes on Contributors SHOUMITA DASGUPTA, PhD, is an Associate Professor, Department of Medicine, Biomedical Genetics Section, and Assistant Dean of Admissions, Boston University School of Medicine, Boston, MA, USA.

Keywords Diverse learning, genetics, cultural.

References 1. Council on Graduate Medical Education.

Minorities in Medicine: An Ethnic and Cultural Challenge for Physician Training. An Update. Seventeenth Report. Rockville, MD: U.S. Department of Health and Human Services; 2005. Accessed at http://www.hrsa.gov/ advisorycommittees/bhpradvisory/cogme/Reports/seventeenthrpt.pdf on September 12, 2011.

2. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305–10.

3. Betancourt JR. Cultural competence - Marginal or mainstream movement? N Engl J Med. 2004; 351: 953-855.

4. Betancourt JR. Cross-cultural medical education: conceptual approaches and frameworks for evaluation. Acad Med. 2003; 78: 560 – 569.

5. Loudon RF, Anderson PM, Gill PS, Greenfield SM. Educating medical students for work in culturally diverse societies. JAMA. 1999;282:875 – 880.

6. Flores G, Gee D, Kastner B. The teaching of cultural issues in US and Canadian medical schools. Acad Med. 2000;75:451

7. International Human Genome Sequencing Consortium. Initial sequencing and analysis of the human genome. Nature. 2001; 409:860-921.

8. Venter, JC et al. The sequence of the human genome. Science. 2001; 291:1304-1351.

9. Jorde LB and Wooding SP. Genetic variation, classification, and ‘race.’ Nature Genetics. 2004; 36:S28-S33.

10. Rotimi CN. Are medical and nonmedical uses of large-scale genomic markers conflating genetics and ‘race’? Nat Genet 2004; 36: S43-S47.


11. Jorde LB. The distribution of human genetic diversity: a comparison of mitochondrial, autosomal, and Y chromosome data. Am. J. Hum. Genet. 2000; 66: 979-988.

12. Bamshad M. Genetic Influences on Health: Does Race Matter? JAMA. 2005; 294(8):937-946.

13. Shields AE, Burke W, Levy DE. Differential use of available genetic tests among primary care physicians in the United States: Results of a national survey. Genet Med. 2008; 10:404-414.

14. Suther S and Kiros G-E. Barriers to the use of genetic testing: A study of racial and ethnic disparities. Genetics in Medicine. 2009;11(9): 655-662.

15. Thurston VC, Wales PS, Bell MA, Torbeck L, and Brokaw JJ. The current status of medical genetics instruction in the U.S. and Canadian Medical Schools. Acad. Med. 2007; 82(5): 441-445.

16. Warren NS. A Genetic Counseling Cultural Competence Toolkit; 2010. Accessed at http://www.geneticcounselingtoolkit.com on March 30, 2012.

17. Burke W, Fryer-Edwards K, and Pinsky L. Genetics in Primary Care (GPC) Training Program Curriculum Materials; 2001. Accessed at http://genes-r-us.uthscsa.edu/resources/ genetics/primary_care.htm on March 31, 2012.

18. Reynolds PP, Kamei RK, Sundquist J, Khanna N, Palmer EJ, and Palmer T. Using the PRACTICE mnemonic to apply cultural competency to genetics in medical education and patient care. Acad Med. 2005; 80(12):1107-1113.

19. Long KA, Thomas SB, Grubs RE, Gettig EA, and Krishnamurti L. Attitudes and beliefs of African-Americans toward genetics, genetic testing, and sickle cell disease education and awareness. J Genet Counsel. 2011; 20:572-592.

20. U.S. Census Bureau Newsroom. 2010 Census shows America’s Diversity;March 24, 2011. Accessed at http://www.census.gov/ newsroom/releases/archives/2010_census/cb11-cn125.html on March 31, 2012.

21. Association of American Medical Colleges. Underrepresented in Medicine Definition. March 19, 2004. Accessed at https://www.aamc.org/initiatives/urm/ on December 17, 2012.

22. Dasgupta S. Sickle Cell Trait and Sickle Cell Disease: A Case Study. MedEdPORTAL; 2009. Available from: www.mededportal.org/ publication/7920

23. Michaelsen LK, Parmelee DX, McMahon KK, and Levine RE. Team-Based Learning for Health Professions Education. Sterling, VA: Stylus Publishing, November 2007.

24. Association of American Medical Colleges. Cultural Competence Education. 2005. Accessed at https://www.aamc.org/download/ 54338/data/culturalcomped.pdf on April 25, 2012.

25. Association of American Medical Colleges and Association of Schools of Public Health. Cultural Competence Education for students in Medicine and Public Health. 2012. Accessed at https://members.aamc.org/eweb/upload/Cultural Competence Education_revisedl.pdf on July 23, 2012.


Supplemental Content 1 Medical Genetics Course Meetings

Medical Genetics

Course Director:

Shoumita Dasgupta, Ph.D. Department of Medicine

Associate Professor

Class

Lecture 1: Gene and Genome Organization Gene structure, chromatin organization, gene expression and imprinting, genotypes and phenotypes, inheritance of chromosomes, and basic Mendelian principles

Lecture 2: Chromosomes and Chromosomal Abnormalities Mitotic and meiotic nondisjunction, abnormalities of chromosome number and structure, uniparental disomy, mosaicism, FISH and karyotyping

Lecture 3: Molecular Genetic Abnormalities Mutation and disease, monogenic syndromes, trinucleotide repeat expansion diseases, and mitochondrial disorders

Transmission of Genetic Abnormalities Pedigree Workshop

Lecture 4: Gene Regulation and Development Transcription factors, role of environment and teratogens in development, and congenital malformations

Lecture 5: Cancer Genetics and Genomics Tumor suppressor genes and oncogenes, loss of heterozygosity, gene activation by duplication or translocation, DNA repair and genome instability, and genomic diagnostics for cancer

Lecture 6: Identification of Genetic Basis of Disease Linkage and gene mapping, association studies, twin studies, pleiotropy, multifactorial disease, modifier genes, and penetrance

Patient panel: Breast cancer testing Patient panel: Trisomy 18

Lecture 7: Genetic Screening and Prenatal Diagnosis Types and methods of screening: population screening, newborn screening, screening for heterozygotes, and screening in pregnancy

Lecture 8: Testing for disease susceptibility Molecular methods and limitations of linked marker and disease locus tests

Patient panel: Huntington’s Disease testing

Lecture 9: Genetic Frontiers The Human Genome Project, microarrays, pharmacogenomics, RNAi and gene therapy, direct-to-consumer genetic testing

Lecture 10: Genetic Counseling: Principles and Practice The components of a genetic counseling interaction, when to make a referral to a genetic counselor, and communication techniques used in genetic counseling

Small Group Clinical case study: Sickle Cell Trait and Sickle Cell Disease

Lecture 11: Ethics and the New Genetics Eugenics, information privacy, health insurance, racial discrimination




ORIGINAL RESEARCH

Can PBL Group Assignment Affect Examination Performance?

Edward C. Klatt & Tina L. Thompson Mercer University School of Medicine, Savannah, GA, USA

Abstract Medical student examination performance in an integrated problem-based learning (PBL) curriculum related to group and faculty facilitator (tutor) assignment has not been well studied. The aim of this study is to investigate whether the PBL group and tutor to which a student is assigned affect examination performance. We found that only 3.6% of all groups had non-Gaussian student examination score distributions. Tutorial group average scores varied by less than 10% from the examination mean. Faculty tutor experience in PBL or expertise by either clinical or basic science background did not appear to have a significant effect upon student knowledge based examination performance, as measured within an integrated basic science PBL curriculum.

Introduction The problem-based learning (PBL) format for medical curriculum delivery has been utilized for over 40 years. Though there are differences in PBL implementation, the core of this format is small group teaching with a patient case for discussion. Each small group is given latitude in defining learning issues to explore within the tutorial sessions. There is progressive development of clinical cases for discussion through exploration of learning issues. By its nature, PBL is an integrative format, because the clinical cases may have learning issues that direct students to knowledge content in multiple basic and clinical science disciplines.1 During a PBL group session students discuss clinical cases under the facilitation of at least one faculty member. Ideally, there are no more than 8 and no less than 5 students in each small group in order to encourage participation and interaction among students. The faculty tutor’s role is primarily to keep the students engaged and make sure all students participate. Faculty may provide direction to the group when needed to keep discussions cogent to the clinical case. However, faculty should refrain from being overly directive and dominating the discussion by lecturing, presenting their own information, or just answering student questions.2

Faculty with expertise in either clinical or basic science knowledge may aid in keeping students on track with discussions cogent to the case content. However, the open-ended nature of PBL puts students in charge, is not stifling of creativity or exploration, and allows novice students to formulate learning issues that may not always take the direction that an expert might take. In PBL, the journey is as important as the destination, and the group interaction process as important as the knowledge content, to achieve educational goals. Therefore, faculty who are case content experts may need to refrain from jumping into discussions or just telling the students what they know. Moreover, a single faculty member has neither the expert knowledge of all content areas of multidisciplinary cases nor the time to disseminate that knowledge in a group session. Previous studies have shown that the effect of tutor expertise on the learning process was not associated with a difference in learning outcome when just factual knowledge was assessed by traditional methods.3-5 Faculty who have prior experience with small group teaching may have insights into facilitation and case discussion that may make the group discussion more productive. Students may think that faculty who are not experienced with group facilitation may not help the group. A prior study of tutor background showed that clinically qualified PBL tutors used their subject-matter knowledge

Corresponding author: Edward C. Klatt, MD, Department of Biomedical Sciences, Mercer University School of Medicine 4700 Waters Avenue, Savannah, GA 31404; Tel:+1 912-350-1728; Fax: +1 912-350-1765; email: [email protected]


significantly more than non-clinical tutors, and they were seen as being more empathic with their students, but a correlation with examination scores was not done.6 Faculty expertise in group facilitation has been shown to positively affect learning of students through stimulation of active and constructive learning, self-directed learning, and collaborative learning to enhance the quality of the problems and group functioning, as well as achievement on examinations.7 However, prior experience alone does not guarantee that faculty can provide appropriate guidance to students. The same tutoring mistakes may be made over and over. Another prior study demonstrated no statistically significant difference in scores of students in groups with experienced versus inexperienced tutors.8 In PBL, students are given a set of objectives that clarify the breadth and depth of knowledge content of subject areas for which students are responsible to learn for examination purposes. Since not all objectives can be covered in the group time available, each group may set its own agenda to cover some of those objectives, and PBL students must develop individual study plans that incorporate all assigned objectives, not just those covered in their group sessions. Since PBL is a learning process that emphasizes interaction among group members with generation of learning issues and discussion, the group may enhance assigned knowledge-based objectives.9 Therefore, we conducted this study to investigate whether student examination performance was related to the PBL group and faculty tutor assignment.

Methods At our medical school the preclinical basic science curriculum is taught in 12 modules from 5 to 7 weeks long with 9 hours of small group tutorial sessions per week. Students are numerically graded by a single integrated multiple-choice examination following each module, and each of these examinations included at least 10 of 12 basic science disciplines: anatomy, embryology, behavioral science, biochemistry, genetics, histology, immunology, microbiology, neuroscience, pathology, pharmacology, and physiology. The PBL modules for this study and their order of placement in the curriculum included: cellular basis of medicine (CL) first, neurology (NE) fifth, musculoskeletal (MS) sixth, cardiovascular (CV) eighth, and endocrine (EN) twelfth. Student and

group numbers are shown in Table 1 for the six medical student classes of 2008 through 2013 in the years from 2006 to 2011. There was a single campus in the first 4 years, and there was a second campus for the classes of 2012 and 2013. There were 8 to 9 tutorial groups per module at the original campus, and 4 groups per module at the second campus. Each tutorial group had from 5 to 8 students led by a single faculty facilitator (tutor). Assignment of both faculty and students to groups was random and changed for each module. Faculty who had facilitated at least 4 prior PBL modules were deemed seasoned, experienced tutors. Each module had a study guide that detailed the learning objectives for the basic sciences covered in the integrated multidisciplinary multiple choice question examination given at the end of the module. The student scores were recorded for each tutorial group and faculty tutor. Student ratings of tutors were collated for all groups. Tutor ratings of students in the groups were collated for the last two years of the study for which these data were available. A one-way analysis of variance (ANOVA) test was performed using the method of Kolmogorov and Smirnov applied to individual student examination scores by module group and by tutor, with Tukey-Kramer Multiple Comparison test if P<0.05 for the ANOVA. A Fisher’s exact test was used to compare average group examination scores by faculty background and experience. A linear regression analysis was performed for comparison of tutor scores of students by module with students’ examination scores for P<0.05.

Results There were 76 individual faculty members tutoring from 1 to 12 groups each over 6 years of the study. Tutors included 37 clinical discipline faculty representing family medicine, internal medicine, obstetrics & gynecology, pediatrics, psychiatry, and surgery departments. There were 39 basic science faculty tutors representing the disciplines of anatomy, embryology, behavioral science, biochemistry, genetics, histology, immunology, microbiology, neuroscience, pathology, pharmacology, and physiology. As shown in Table 1, there were 302 total groups, with clinical faculty tutoring 44% (139 groups). Half of the groups (49%) were led by faculty with content expertise for the module. Seasoned PBL tutors led 79% of the groups. A total of 2133 individual student examination scores were recorded.


Module Class Year

Number of

Students

Number of

Groups

Percent of Tutors Who Were Group Variance

from Exam Average (%)

Ratings

Clinician (%)

Expert (%)

Seasoned (%)

Of Tutor By Students

(% Positive)*

Of Student By Tutors

(Average)**

CL 2008 62 9 44 44 100 -6.8 to +3.9 89

CL 2009 65 9 33 44 100 -3.5 to +4.1 100

CL 2010 63 9 44 33 100 -5.6 to +5.3 89

CL 2011 65 9 44 22 100 -5.2 to +3.6 100

CL 2012 93 13 31 31 92 -9.3 to +5.2 92 4.1

CL 2013 95 13 38 38 62 -6.2 to +5.4 92 4.2

NE 2008 58 9 78 22 89 -5.3 to +3.6 100

NE 2009 63 9 67 33 78 -4.4 to +3.1 89

NE 2010 58 9 56 33 89 -7.8 to +4.9 89

NE 2011 72 9 56 44 100 -6.7 to +5.1 100

NE 2012 90 13 46 38 54 -5.0 to +5.9 92 4.7

NE 2013 92 13 46 54 62 -2.6 to +6.7 92 4.5

MS 2008 58 9 44 56 100 -5.5 to +3.9 89

MS 2009 63 9 33 67 100 -5.2 to +4.6 89

MS 2010 58 9 33 56 100 -2.4 to +3.8 100

MS 2011 60 9 44 89 78 -5.2 to +2.9 100

MS 2012 89 13 38 62 54 -3.7 to +5.7 92 4.4

MS 2013 92 13 31 62 38 -4.0 to +4.0 92 4.2

CV 2008 58 8 63 50 88 -3.3 to +7.6 89

CV 2009 63 9 44 56 78 -3.6 to +4.4 89

CV 2010 57 8 63 50 88 -4.1 to +3.3 100

CV 2011 61 8 63 63 100 -5.3 to +3.4 88

CV 2012 91 13 54 62 77 -9.5 to +4.5 92 4.5

CV 2013 90 13 54 54 69 -5.7 to +4.6 92 4.2

EN 2008 57 8 50 38 75 -5.7 to +2.9 88

EN 2009 63 9 33 33 100 -3.1 to +3.2 100

EN 2010 57 8 50 50 88 -2.2 to +6.9 100

EN 2011 60 8 50 50 75 -4.7 to +4.0 88

EN 2012 90 12 33 58 58 -6.2 to +4.9 92 4.9

EN 2013 90 12 42 67 50 -2.8 to +2.9 92 4.5

Totals / Averages

2133 302 46% 49% 79% 93% 4.4

Table 1: PBL Group Results by Curriculum Module and Class Year * % of students positively indicating that they would choose to have the same tutor again ** On a 1 to 5 Likert scale with 5 being highest


Only 11 groups (3.6%) with 9 different faculty tutors (2 CL, 1 NE, 3 MS, 3 CV, 2 EN) had non-Gaussian student examination score distributions, 3 above and 8 below the class examination average for the module. In 5 of these 11 groups, just 6 failing students accounted for this statistical effect, and all 6 of these students performed poorly for the entire academic year, not just in that single module. The average examination scores for the 302 groups ranged from 7.6% above to 9.5% below the class average for the modules (Table 1). Of the 139 groups led by clinicians, 63 (45.3%) had below average examination scores for the module, while of 163 groups led by basic scientists, 81 (49.7%) group examination scores were below average (p=0.68). Of the 238 groups facilitated by faculty experienced with PBL, 144 (47.9%) had below average examination scores, while 31 of 64 (48.4%) groups led by less experienced PBL faculty had examination scores below the class average (p=1). As shown in Table 1, student ratings of tutors were uniformly high, with 93% of all students responding positively to the question, “Would you choose to have your tutor again?” Tutor ratings of students were available for the last 2 years of our study. On a 5-part Likert scale, with 1 scored as failing, 2 marginal, 3 passing, 4 good, and 5 excellent, the average score assigned to students was 4.4. In 4 of these modules there was a significant (P<0.05) correlation between the individual student assigned group score and the exam score, and in 2 of these the correlation was very significant (P<0.01).

Discussion In many years of teaching we have often received evaluation feedback from students that, “If only I had been in the group with Dr. ___, I would have scored much higher on the examination.” In this study we showed no significant correlation between either PBL group assignment or faculty tutor background or experience and student scores on integrated examinations of the knowledge content covered by the PBL groups. The Gaussian, or normal, distribution as a bell curve predicts less than 5% of values fall outside of 2 standard deviations. Of the 3.6% of our PBL groups with a non-Gaussian distribution of student scores, over half included the poorest performing students. Neither faculty tutor experience with PBL nor background expertise as a clinician or basic scientist predicted examination scores.

A prior study of PBL group interaction showed that the level of group involvement by students did not significantly impact their performance on quizzes assessing their knowledge and application of biomedical learning issues.10 Students who do not embrace the PBL process may be excellent individual learners who can do well on examinations of knowledge content. Conversely, there are students who are very active participants in PBL but who struggle with examinations. Faculty tutors alone cannot change student knowledge, skills, or attitudes. Faculty cannot learn for students any more than one can do physical exercise for another person. Students must be prepared for self-directed learning methodologies outside of a group process.11 Does the PBL group dynamic provide an advantage to students who are in groups that function more effectively? A study of student perceptions of small group teaching identified tutor characteristics, a non-threatening group atmosphere, clinical relevance and integration, and pedagogical materials that encourage independent thinking and problem solving as the most important characteristics of effective small groups. Tutor characteristics included personal attributes and the ability to promote group interaction and problem solving.12 We found that our students gave high evaluations to nearly all group tutors (93%), suggesting that there were no perceived major problems in our PBL process, and that groups functioned effectively. The Gaussian distribution of our students’ scores supports this. PBL is both a process as well as a knowledge content delivery method. The value of PBL in students’ education may not be measured solely by knowledge-based examinations. Reported benefits of PBL include improved clerkship and residency performance, greater clinical competence, and increased diagnostic accuracy.13 Schmidt et al showed that learning in a PBL environment results from both group collaboration as well as individual knowledge acquisition.14 Von Bergmann et al found a significant correlation between PBL process skills evaluated by faculty tutors and subsequent student scores on content acquisition tests, but just a single class of students was studied, and there was no analysis of results by individual tutors.15 We found a similar correlation in 4 of 10 modules for which data were available, and it is likely that the overall high student rating scores assigned (4.4 on average on a 1 to 5 scale) affected the correlation.


The overall high ratings for both faculty and students in our study suggested that the groups were perceived as functioning well. Do perceptions of the PBL process by faculty and students accurately reflect student performance? Faculty tutors tend to overestimate their students’ knowledge base.16 Students involved in a tutorial group tend to overestimate their own performance as well as performance of their peers.17 In a prior study, students’ progression of knowledge and understanding of a topic increased their autonomy and group cognitive engagement. Students who had more knowledge, whether gained inside or outside the group process, demonstrated more autonomy, more self-determination, and more situational cognitive engagement.18 More autonomous, cognitively engaged students may be less dependent upon faculty expertise and experience for their learning outcomes. PBL student performances on general knowledge examinations such as the USMLE steps 1 and 2 have been studied and compared with scores of students from medical schools with more traditional curricula. Hoffman et al found that PBL students scored higher 6 of 10 times on step 1, with focus on basic science, and higher 6 of 9 times on step 2 with more clinical science content, when comparison was made with a traditional curriculum.19 PBL helps drive lifelong learning skills that carry forward to future training and practice venues.

Conclusion We found that the tutorial group to which students were assigned with faculty tutors having either clinical or basic science background or experience with PBL had no significant effect upon student knowledge based examination performance measured within an integrated basic science PBL curriculum.

Notes on Contributors EDWARD C. KLATT, MD, is Professor of Pathology, Department of Biomedical Sciences, Mercer University School of Medicine, Savannah, GA, USA. TINA L. THOMPSON, PhD, is Associate Professor of Neuroscience, Department of Biomedical Sciences, Mercer University School of Medicine, Savannah, GA, USA.

Keywords Problem based learning, examination, medical education, faculty facilitator

References 1. Neville AJ. Problem-based learning and medical

education forty years on: a review of its effects on knowledge and clinical performance. Med Princ Pract 2009;18:1–9.

2. Papinczak T, Tunny T, Young L. Conducting the symphony: a qualitative study of facilitation in problem-based learning tutorials. Med Educ 2009;43(4):377-383.

3. Schmidt HG, van der Arend A, Moust JH, Kokx I, Boon L. Influence of tutors' subject-matter expertise on student effort and achievement in problem-based learning. Acad Med 1993;68(10):784-791.

4. Kwizera EN, Dambisya YM, Aguirre JH. Does tutor subject-matter expertise influence student achievement in the problem-based learning curriculum at UNITRA Medical School? S Afr Med J 2001;91(6):514-516.

5. Matthes J, Marxen B, Linke RM, Antepohl W, Coburger S, Christ H, Lehmacher W, Herzig S. The influence of tutor qualification on the process and outcome of learning in a problem-based course of basic medical pharmacology. Naunyn Schmiedebergs Arch Pharmacol 2002;366(1):58-63.

6. Groves M, Régo P, O'Rourke P. Tutoring in problem-based learning medical curricula: the influence of tutor background and style on effectiveness. BMC Med Educ 2005 Jun 7;5(1):20.

7. Van Berkel HJ, Dolmans DH. The influence of tutoring competencies on problems, group functioning and student achievement in problem-based learning. Med Educ 2006;40(8):730-736.

8. Park SE, Susarla SM, Cox CK, Da Silva J, Howell TH. Do tutor expertise and experience influence student performance in a problem-based curriculum? J Dent Educ 2007;71(6):819-824.

9. Veale P. Prospective comparison of student-generated learning issues and resources accessed in a problem-based learning course. Med Teach 2007;29(4):377-382.

10. Romito LM, Eckert GJ. Relationship of biomedical science content acquisition performance to students' level of PBL group interaction: are students learning during PBL group? J Dent Educ 2011;75(5):653-664.

11. Hendry GD, Ginns P. Readiness for self-directed learning: validation of a new scale with medical students. Med Teach 2009;31(10):918-920.


12. Steinert Y. Student perceptions of effective small group teaching. Med Educ.2004;38(3):286-293.

13. Hartling L, Spooner C, Tjosvold L, Oswald A. Problem-based learning in pre-clinical medical education: 22 years of outcome research. Med Teach 2010;32(1):28-35.

14. Schmidt HG, Rotgans JI, Yew EH. The process of problem-based learning: what works and why. Med Educ 2011;45(8):792-806.

15. von Bergmann H, Dalrymple KR, Wong S, Shuler CF. Investigating the relationship between PBL process grades and content acquisition performance in a PBL dental program. J Dent Educ 2007;71(9):1160-1170.

16. Whitfield CF, Xie SX. Correlation of problem-based learning facilitators' scores with student performance on written exams. Adv Health Sci Educ Theory Pract 2002;7(1):41-51.

17. Machado JL, Machado VM, Grec W, Bollela VR, Vieira JE. Self- and peer assessment may not be an accurate measure of PBL tutorial process. BMC Med Educ 2008 Nov 27;8:55.

18. Rotgans JI, Schmidt HG. Cognitive engagement in the problem-based learning classroom. Adv Health Sci Educ Theory Pract 2011;16(4):465-479.

19. Hoffman K, Hosokawa M, Blake R Jr, Headrick L, Johnson G. Problem-based learning outcomes: ten years of experience at the University of Missouri-Columbia School of Medicine. Acad Med 2006;81(7):617-625.




ORIGINAL RESEARCH

Pediatric Examinations Content Validity Comparison:

In-House Versus NBME Examination

Hassib Narchi Department of Pediatrics, College of Medicine & Health Sciences, Al Ain, United Arab Emirates

Abstract Objective: Comparison of the content validity of an in-house summative pediatric examination (clinical examination, oral and non-clinical skills assessment) and the American National Board for Medical Examiners Pediatrics Subject Examination (NBME-P) taken by sixth year medical students at the end of their senior pediatric clerkship in our institution. Methods: The content validity of both examinations was compared over five academic years using a modified version of Bloom's taxonomy of educational objectives: A- knowledge and comprehension, B- application and analysis, C- synthesis and evaluation, D- Attitude and E- Skills. We analyzed which of these educational objectives were evaluated by each assessment tool. Results: Knowledge and comprehension, application and analysis, synthesis and evaluation were adequately evaluated by the clinical, the oral, the non-clinical and the NBME examinations, although not necessarily by the individual components of each assessment. Attitude was adequately tested by the clinical examination only, while psychomotor skills were adequately evaluated only by the clinical and the non-clinical examinations. Conclusions: No single assessment tool adequately evaluated all educational objectives. The results have led us to modify our examination assessment tools of medical students during a clerkship. A diversified range of assessment tools is still needed for that purpose.

Introduction As assessment of students’ learning often relies on global evaluations in un-standardized settings with limited samples of clinical behavior, medical schools strive to provide accurate and reliable assessments of trainees’ competence. Most institutions require students to take an examination following each clerkship. The wide range of assessment tools available reflects that none on its own adequately and comprehensively evaluates all the learning outcomes expected from medical students.1 At the College of Medicine and Health Sciences (CMHS), United Arab Emirates (UAE) University, following an 8-week junior pediatric clerkship a year earlier, sixth year medical students undergo a 4-week senior pediatric clerkship before taking both an in-house summative examination (IHE) and the National Board for Medical Examiners (NBME) Pediatric Subject Examination (NBME-P).

A. The IHE has three components:

1. A one-hour faculty-observed assessment of student’s professionalism and competence in history-taking, physical examination, diagnosis and treatment of common pediatric problems. Each observed performance is evaluated and ranked separately by two faculty and, to ensure examination consistency, children with similar medical problems are selected whenever possible. The examiners directly observe and assess the students’ self-introduction to the family, their history taking (present illness, review of systems, perinatal, family history, development milestones, dietary, immunizations, psychosocial background, etc.), and their physical examination skills (general observation, taking vital signs and growth parameters, examination of a specified system, e.g. respiratory, cardiovascular, neurological) using a fluent technique. Communication skills are also observed and

Corresponding author: Professor Hassib Narchi, Department of Pediatrics, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, P.O Box 17666, United Arab Emirates; Tel: +971 3 7137414 ; Fax: +971 3 7672022; email: [email protected]


evaluated (effective use of open and close-ended questions, appropriate response to verbal and non-verbal cues from patient and family, exploration of their perspectives, open and empathic communication, negotiation of management plan, and appropriate response to patient or family concerns). Students’ professionalism is assessed by observing their showing of respect, compassion, empathy, to the patient and family, as well as establishing trust, attending to patient’s needs of comfort and respecting confidentiality. This direct observation is followed by a discussion with the student, away from the bedside, where the faculty evaluates the completeness and relevance of the history taken by the student the interpretation of symptoms and of the elicited clinical signs, the clinical judgment, differential diagnosis, selection of appropriate diagnostic studies and interpretation of the results. Also evaluated are the student’s, formulating a management plan, understanding of the risks, benefits and implications for the family, knowledge of the epidemiology, complications, prognosis and prevention of the condition if applicable, in addition to the quality of explanations given by the students to the parents. Students’ attitude regarding ethical issues, awareness of relevant legal frameworks and understanding of their limitations is also evaluated during the discussion.

2. A structured oral examination, with two

examiners, using ten short clinical vignettes, each describing symptoms or physical signs (e.g. limping, abdominal distension, etc.), clinical photographs (e.g. Down syndrome, bow legs), radiographs (e.g. pneumonia, rickets, cardiomegaly), electrocardiograms (e.g. arrhythmia, ventricular hypertrophy), or laboratory data (e.g. pyloric stenosis, acid base imbalance). These items are taken from a questions pool and, although identical for each clerkship rotation, they are changed amongst rotations. During the discussion, the students should demonstrate their competence in the interpretation of symptoms, clinical photographs, radiographs, electrocardiograms, laboratory data, as well as competence in ordering appropriate investigations and planning adequate treatment when asked.

3. an evaluation of non-clinical skills based on two components: (1) the documentation in the logbook of students’ attendance at teaching sessions, attitude and professionalism as evaluated by faculty, participation in ward rounds, case discussions and morning report sessions, in addition to (2) the evaluation of five written case presentations submitted by each student and evaluated on the completeness and relevance of the history and examination, the appropriateness of their selection of investigations and treatment, their critical analysis of the differential diagnosis, investigations and management based on evidence from the published literature. The student is also expected to mention how he/she would have personally managed each of these cases based on critical analysis of available information.

B. The NBME is an American, independent, non-profit organization tasked to develop a nationwide examination which permits medical licensing authorities to evaluate candidates for licensure.2 It is also an international model and resource for testing methodologies and evaluation in medicine, providing a wide range of assessment services to medical schools. The Subject examinations offer standardized, objective discipline-based examinations for use throughout the medical school curriculum, especially as final examinations after courses or clerkships.3,4 They allow institutions to evaluate their students’ performance and compare it with a large, representative group of students at the same stage of training. Advantages include: provision of national and international norms and relevant descriptive information, expertise in preparing these materials, and focus on application and integration of knowledge rather than recall. The measured performance of the students reflects not only the learning specific to their course and clerkship experiences, but also the educational development resulting from their overall medical school experiences. Norms for these examinations are updated yearly for adequate interpretation of students’ performance. Items are selected from item pools based on content and performance statistics and the tests are constructed to be appropriate for a broad range of curricular approaches. Each Subject examination requires students to solve scientific and clinical problems. They have been proven to be high-quality, robust and well-validated assessment tools. The Pediatrics Subject examination consists of two types of high-quality and well-validated multiple choice questions (MCQ) framed in the context of clinical vignettes: (1) one-best-answer (A-


type) questions, making explicit the number of options to be selected, are the most widely used. Each item consists of a focused item-stem (e.g., a clinical vignette) and a lead-in question, followed by a series of options with one correct answer for each item and (2) extended-matching (R-Type) items are organized into sets which use one list of options for all items in the set and candidates must select the one best answer.5,6 Each NBME Subject examination assesses what students have learned about normal development (5-10% of the questions) as well as the entire range of organ systems diseases (such as cardiovascular, neurology, renal and others, with each subset tested with up to 15% of questions). It also assesses important tasks carried out by physicians, such as health promotion and maintenance (5-10% of questions), understanding of mechanisms of disease (25-30% of questions), how to establish a diagnosis (40-45% of questions) and the application of principles of management (10-15% of questions). Any chosen assessment must be aligned with the educational objectives of the teaching and learning activities in that part of the curriculum and the learning outcomes should be pitched at various levels of thinking. Bloom’s taxonomy of educational objectives (Bloom-TEO), developed with the task of classifying educational goals and objectives, identifies three domains of educational activities:7

I. Cognitive, involving mental skills with a

hierarchy of six increasing levels of complexity: 1- knowledge (recall of specific items, dealing with facts, trends, classification, theories and procedures), 2-comprehension (grasping the meaning and intention of information, understanding, paraphrasing, defining and discussing), 3- application (use of previously learned information in new and concrete situations to solve problems, can take information of an abstract nature and use it in concrete situations), 4- analysis (can break down complex information material into simpler parts, revealing their organization and the relationships among them), 5- synthesis (can pull together many disorganized elements , concepts or parts so as to generate a new whole) and 6- evaluation (can make judgments about the value of materials or methods based on some standards or criteria).

II. Affective, with a hierarchy of five levels: 1-

receiving (willing to notice a particular phenomenon, paying attention passively),

2- responding (making response, at first with compliance, later actively, willingly and with satisfaction), 3- valuing (attaching value to the information or object), 4- organizing values (determining interrelationships, adapting behavior to value system, comparing, relating, and elaborating on what has been learned) and 5- characterizing (holding a value and belief that exerts an influence on behavior).

III. Psychomotor (involving manual or physical

skills). This taxonomy is hierarchical (levels increase in difficulty/sophistication) and cumulative, with learning at the higher levels being dependent on having attained prerequisite knowledge and skills at lower levels. Its goal is to focus on all three domains, creating a more holistic form of education. It has been used to evaluate many assessment tools: oral examinations, written examinations, multiple-choice questions and modified essay questions.8-16 It has also been used to evaluate the cognitive levels assessed in courses and examinations, small clinical discussion groups, reflective writing and even clinical diagnosis.17-20 Many studies have evaluated the predictors of performance at the NBME examination, and of the latter on the performance at the USMLE or residency training.6,21,23 However Bloom-TEO has not been used before to evaluate the content validity of the NBME-P, and, to our knowledge, no study has analyzed in detail, or compared, the specific educational objectives evaluated by each (individual) assessment tool. In this study we analyze and compare the content validity of both the IHE and the NBME-P with regard to Bloom-TEO.7 The aim is to ensure that all educational objectives in our curriculum are being adequately assessed and unnecessary duplication of assessments is avoided.

Material and Methods We analyzed and compared the content validity of the pediatric in-house examination (clinical examination, oral examination and assessment of non-clinical skills) and of the NBME-P in the domains of knowledge, skills and attitude as defined in the Bloom-TEO.7 We used a modified version of that taxonomy by the reclassifying the six levels in the cognitive domain into three categories (A: knowledge and comprehension, B: application and analysis, and C: synthesis and evaluation) while the Attitude (D) and Skills domains (E) were analyzed as such.


A. Knowledge: ability in recalling, naming, listing, defining, etc. Comprehension: explaining, describing using own words, comparing, contrasting, providing examples, interpreting, estimating, etc.

B. Application: ability in applying theory,

using a concept in a new context, solving a problem, constructing growth charts or graphs illustrating pathophysiology or genetic pedigree, calculating medication dose based on child’s weight. Analysis: ability in breaking concept into smaller parts and understanding relationships between them, determining which signs and symptoms support the main diagnosis and which are distractors or caused by medication side effects, selecting appropriate investigations, distinguishing between anecdotal information and scientifically proven facts, understanding relevance of a clinical finding.

C. Synthesis: ability in building a structure or

pattern from information from diverse sources, organizing and delivering a plan to solve a problem, classifying the information in a logical model, ranking the differential diagnoses, diagnosing the condition, building a flow chart explaining all symptoms and signs, developing a management plan. Evaluation: making a judgment about the findings, evaluating the relevance and adequacy of the information, developing a diagnosis based on the available facts, comparing and contrasting the results of the clinical findings and the investigations, evaluating the reliability and validity of the investigations and selecting the most appropriate treatment from a range of options.

D. Attitude: general approach to the child and

family, listening attentively, showing sensitivity to social, problems, showing empathy and concern, offering support and counseling.

E. Skills: competence in history taking and

physical examination, appropriate use of an otoscope and ophthalmoscope, writing and presentation skills, using computers for literature search, software use in typing reports, designing tables, charts and preparing presentations.

Using computer-generated random numbers, ten samples of each assessment method for each of the five years of the study were randomly selected. Fifty samples of each assessment method were therefore analyzed. Each sample was individually analyzed as a whole (such as the clinical examination) for the educational objectives it evaluated, without assessing separately the specific contribution of each of its individual components (such as history taking or physical examination or discussion of the possible diagnosis). Each individual assessment tool therefore evaluated more than one educational objective and we calculated for each the number and percentage of assessments that adequately evaluated each individual educational domain. For validation purposes, ten assessment questions (two from each of the 5 years of the study) were randomly selected from each of the clinical, oral, non-clinical skills and the NBME-P. They were independently evaluated by the author and by a faculty not involved in this study, in terms of the modified version of Bloom-TEO. The percentages of agreement between the two raters were 95% for the clinical examination, 88% for the oral examination, 85% for the non-clinical skills and 87% for the NBME questions. Ethical approval was granted by the Al Ain Medical District Human Research Ethics Committee (protocol 09/34) and accepted by the University of Dundee.

Results Fifty of each of the following assessment methods (clinical, oral examinations, non-clinical skills and NBME-P) were analyzed in relation to the modified Bloom-TEO. For each assessment tool, the number and percentage of the assessments adequately evaluating each educational domain were calculated and are shown in Table 1. The educational objectives assessed in the in-house clinical examination Knowledge and comprehension (A), application and analysis (B) and synthesis and evaluation (C) were adequately evaluated by all 50 (100%) clinical examinations although not necessarily by the individual components of each assessment. The analysis and interpretation of the history and of the clinical findings, the presentation and discussion of the findings required knowledge of the condition and understanding of the associated problems and complications. Adequate application and analysis of the information gathered in order to establish a diagnosis and to consider possible differential


diagnoses were also required. Adequate synthesis and evaluation of the available results in order to establish a diagnosis, select investigations and order a treatment were also needed. In addition, attitude

(D) and skills (E) were also adequately evaluated by all (100%) clinical examinations.

In-house examination NBME

Educational objectives Clinical

examination n=50

Oral examination

n=50

Non-clinical skills n=50

n=50

1. Cognitive

A. Knowledge, comprehension 50

(100) 45

(90) 50

(100) 10

(20)

B. Application, analysis 50

(100) 50

(100) 50

(100) 50

(100)

C. Synthesis, evaluation 50

(100) 50

(100) 50

(100) 50

(100)

2. Attitude 50

(100) 0

(0) 5

(10) 10

(20)

3. Skills 50

(100) 0

(0) 50

(100) 0

(0) Table 1: Bloom’s educational objectives assessed in the pediatric in-house and the NBME examinations Number of assessments (percent) fulfilling each objective

The educational objectives assessed in the in-house oral examination Knowledge and comprehension (A) were adequately evaluated by 90% of the oral examinations. Although they were not explicitly tested in 10% of these examinations, they were nonetheless implicitly evaluated as it was expected that the students had already established a correct clinical diagnosis before the applying the subsequent cognitive steps (application, analysis, synthesis and evaluation). All 50 oral examinations (100%) adequately evaluated students’ application and analysis (B) and capability for synthesis and for evaluation (C). All six cognitive levels were adequately evaluated by each of the 50 oral examinations although not necessarily by the individual components of each assessment. Analysis and interpretation of the clinical photograph or x-ray, their presentation and discussion of the findings, required good knowledge and understanding of the problem. Adequate application and analysis of the information gathered in order to establish a diagnosis and to consider differential diagnoses were required. Adequate synthesis and evaluation of the available results to establish a diagnosis and order investigations and treatment were also needed. Attitude (D) was not explicitly tested in any of the oral examinations as none tested the approach to the child and family, listening attentively, showing sensitivity to social, problems, empathy, concern, offering support and counseling.

None of the questions tested the students’ psychomotor skills (E). The educational objectives assessed in the in-house non-clinical assessment All 50 non-clinical examinations (100%) adequately evaluated students’ knowledge and comprehension (A), application and analysis (B) as well as synthesis and evaluation (C) although not necessarily by the individual components of each assessment. The students’ active participation during ward rounds, as well as their presentation and write up of the cases required them to have a good knowledge of the problem. Adequate application and analysis of the information to establish a diagnosis and to consider differential diagnoses were required. Good synthesis and evaluation of the results to establish a diagnosis, order investigations and therapy were also needed. The regular review of the medical literature to guide the students throughout this process also relies on the application of these six cognitive levels. Attitude (D) was not adequately tested in any of the non-clinical examinations. The case write up exercises could not assess the adequacy of the student’s general approach to the child and family, listening skills, expression of awareness and sensitivity to psychosocial issues, evidence of concern, support or counseling. Nor did it directly observe and assess the students arranging, combining, comparing, generalizing, integrating, organizing and synthesizing the ideas used for the presentation. However, as completion


of assignments and adherence to attendance rules were directly evaluated from the students’ log book, and as this evaluation represented 10% of the scores of the non-clinical skills assessment, we estimated that attitude was adequately evaluated by 10% of the questions of that assessment. Skills (E) were adequately tested in all of these examinations (100%) as all the write ups adequately evaluated the students’ writing and presentation skills, use of computer for literature search, reports production on a word processor, design of tables and charts, etc. The educational objectives assessed in the NBME-P Knowledge and comprehension (A) were adequately tested in only 20% of the NBME-P questions. Although not explicitly tested in the remaining 80%, it was implicit because the students had to have already established a correct clinical diagnosis (knowledge and comprehension) before the application, analysis, synthesis and evaluation could be subsequently assessed. Application and analysis (B) and synthesis and evaluation (C) were adequately evaluated by all (100%) questions. The students’ analysis and interpretation of the clinical vignette, their analysis and integration of the information required them to have a good knowledge and understanding of the condition of the problem to solve. Application and analysis of the available information to establish a diagnosis and consider differential diagnoses were also required. Synthesis and evaluation of the results was needed to establish a diagnosis and order investigations and treatment. Only 20% of the questions adequately assessed attitude (D) by evaluating students’ empathy to the patient, exploring the psychosocial implications of the disease and treatment, offering counseling, advice and support in an empathic manner. The questions were also useful to evaluate the student’s attitude to arranging, combining, comparing, generalizing, integrating, organizing and synthesizing the ideas to answer the questions. None (0%) of the NBME questions adequately tested for psychomotor skills (E).

Discussion The primary aim of a medical school is to provide the society with clinically competent, responsible and caring physicians. Formative and summative students’ assessment throughout medical training are used to measure if these aims were attained, not only in the cognitive domain, but also in skills and attitude. Many of the available assessment tools evaluate primarily lower cognitive level, essentially recall.14 A few tools separately assess higher

cognitive levels, skills or attitude.16 This has resulted in the use of comprehensive and integrative evaluation instruments to measure knowledge on various cognitive levels, attitudes and skills.24 As in our institution we use different assessment tools to evaluate our students in all educational domains, we evaluated these tools using Bloom-TEO which has been successfully used to evaluate many types of examinations.14,19,25 Our results showed that, in addition to assessing many domains evaluated by the NBME-P, the clinical examination also evaluated very effectively students’ knowledge, comprehension, affective and psychomotor skills, which the NBME-P lacked. It was also better than the oral examination at assessing knowledge and comprehension and outperformed the non-clinical skills assessment in evaluating attitude. These findings confirm that all the educational objectives were adequately evaluated by the clinical examination, fulfilling therefore all of Bloom’s-TEO.20 The oral examination reflects students understanding of the concepts taught, their ability to relate methods of problem solving and promotes self-organization and discipline.26 It assesses their deep understanding of the subject and fulfills most of Bloom-TEO. However, like the NBME-P, it is poor at assessing students’ attitude and skills. The non-clinical skills assessment evaluated students’ attendance at teaching sessions and their case presentations, assessing their knowledge, skills and professional behavior.27 It covered all educational domains except attitude, which was evaluated in only 10% of the questions. The educational domains evaluated included skills and attitude but less comprehensively than the clinical examination. Although the NBME-P relies on MCQs, the questions involve more than simple recall and also effectively evaluate students’ interpretation, reasoning ability and problem solving.12 Our findings confirm that it adequately evaluated knowledge and comprehension, as although they were not explicitly tested, this was implicit, as discussed earlier. However, it was inadequate at assessing skills and attitude, including communication and confidentiality. Although the overall educational objectives might be adequately assessed in each of these examinations, we recognize that each examination might have looked only at just a few aspects of a particular educational objective. For example, while the


NBME-P might be looking into the domains attitude and professionalism towards some ethical issues, these same domains might have been be assessed differently in the IHE when evaluating students’ communications or confidentiality. With the exception of the clinical examination, no single assessment tool could, by itself, evaluate all the educational objectives. It would be therefore tempting to conclude that a clinical examination assessment is all what is needed to evaluate that all the educational objectives have been met by the students’ at the end of a clerkship. But we caution about this over-simplification. Although it adequately evaluates all six levels of cognition, in addition to the domains of attitude and psychomotor skills, this assessment focuses on only a handful of paediatric conditions and the student is not assessed on a wide range of illnesses. For example, evaluating student knowledge during the clinical examination of an infant with a respiratory problem conveys no information on his/her performance with a child of a different age or with a different pathology. Other tests such as the oral examination or the NBME-P can more effectively evaluate students’ cognitive domain across a wide range of conditions. The attitude evaluated during the clinical examination may not reflect at all student’s attitude in real life, as he/she might display an attitude when observed which is very different from his/her overall attitude during the clerkship. Likewise, the psychomotor skills assessed during the clinical examination could be purely mechanistic (proper technique of auscultation but without eliciting the correct auscultatory findings and their interpretation), and when assessed in a focused examination (such as cardiovascular) it may not reflect the student’s performance in another system (neurological, cardiovascular, etc.). The study highlighted some weaknesses in our different assessment tools which led us to modify our examination methods. Despite all its strengths, the clinical examination still has many limitations, as discussed earlier. Although objective structured clinical examination (OSCE) is a tool we have considered using, we have instead opted to replace the clinical examination with mini clinical examinations (MiniClEx) which remedy most of its limitations and also constitutes the equivalent of an in-training periodical evaluation. The oral examination had no value in assessing attitude and skills, and its assessment of knowledge was found to incompletely evaluate the Bloom’s TEO. As a result, we have decided to remove it from our examination.

The non-clinical examination did not adequately assess students’ attitude. The quality of evaluation of the case write-up varied widely, probably because of the subjectivity of the evaluating faculty and the lack of a standardized assessment form. As a result, we have decided to have multiple raters for each write up, using a standardized assessment form. As students’ attendance at teaching sessions did not adequately assess students’ attitude, we have decided to also remove it as an assessment tool. Despite the limitations of the NBME Subject Examination described earlier, we have decided to keep it as part of our clerkship examinations because the very wide and comprehensive range of conditions it tests for, which considerably limits sampling bias. Except for the clinical examination, there seems to be a paucity of tools to assess the affective and the psychomotor learning domains. To ensure more comprehensive, more reliable and more authentic assessment methods, especially for the students’ psychomotor skills, attitude and professionalism, we are also still considering other assessment tools to complement the modifications we have already made to our examinations. These include 360 degree evaluation, checklist evaluation of live performance, procedure or case logs and portfolios.3

Conclusion Using a modified version of Bloom's taxonomy of educational objectives to evaluate the content validity of the assessment tools used at the end of pediatric clerkship examination, we found that knowledge, application and analysis, synthesis and evaluation were adequately evaluated by the clinical, the oral, the non-clinical and the NBME examinations, although not necessarily by the individual components of each assessment. Attitude was adequately tested by the clinical examination only, while psychomotor skills were adequately evaluated only by the clinical and the non-clinical examinations. As most assessment methods did not adequately evaluate all the educational domains, especially the affective and the psychomotor learning domains a diversified range of assessment tools is still needed to adequately evaluate medical students during a clerkship. The results of the study have led us to remove some assessment tools of the examination, to replace them with new ones and to make modifications to some of those that we are still using. The aim is to ensure more comprehensive, valid and reliable assessment methods.


Acknowledgements The author wishes to thank Dr. John McAleer, Senior Lecturer, Centre for Medical Education, Dundee, for his supervision of this project, to Professor Michelle Mclean for her contribution to the independent evaluation of the assessment tools used in this study, Dr. Sami Shaban and Dr. Sulaiman Al Hammadi, at the College of Medicine and Health Sciences, United Arab Emirates University, for allowing access to the medical students’ marks.

Keywords Clinical Clerkship; Students, Medical; Educational Measurement

Notes on Contributors HASSIB NARCHI, MD, FRCP, FRCPCH, MSc Epid, MMEd, is professor in the Department of Pediatrics, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates

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ORIGINAL RESEARCH

Racial-Ethnic Differences in Medical Students’ Experiences of Professionalism:

A Mixed-Methods Study

Lavjay Butani, Ana-Maria Iosif, Alyn Kelley, Omar Washington &

Andreea L. Seritan University of California Davis Medical Center, Sacramento, CA, USA

Abstract Background: Professionalism in the medical environment is a complex construct, dependent as much on the learner as on the context and climate. There are no data on how experiences of learners, related to professionalism, vary by learner ethnicity. Purpose: Explore ethnic differences in medical student experiences of professionalism. Methods: Quantitative and qualitative data from a survey of medical students exploring opinions and experiences related to professionalism were used. Two investigators categorized narratives into themes. Statistical analyses included Fisher's exact and Wilcoxon tests. Results: 114 of 331 (34%) students (55% Caucasian) responded. Caucasians more frequently (73% versus 43%, p 0.002) found peer role models to be effective teachers of professionalism. Non-Caucasians more often reported unprofessional behaviors from faculty, staff or administration (55% versus 39%, p 0.03); these pertained more commonly to interpersonal interactions. Conclusions: Compared to other ethnicities, Caucasian students identify peer role models more frequently as teachers of professionalism. Non-Caucasian students more often report unprofessional behaviors from faculty, staff, or administration. This may arise from differences in perception, true bias or both.

Introduction The clinical learning environment has a profound impact on the development of professional values of learners.1 The critical roles of one’s upbringing as well as the influence of professional role models, both peers and faculty, in teaching professional values, have been emphasized in the medical education literature.2 The literature also describes how professionalism is culture dependant.3 Professional values and behavior are vital, not only for maintenance of the highest standards of patient care, but also since they impact the learning climate. In today’s ethnically diverse learner population, it is therefore critical to understand differences in beliefs and experiences of learners of different ethnicities with respect to the construct of professionalism. Understanding ethnic differences in learners’ experiences with professional and unprofessional

behaviors could allow educators to explore and address barriers to the promotion of professional values. This information could then enhance the ability of educators to appropriately model professional behavior, improve the learning climate, prevent burnout and also improve patient well-being and satisfaction. While there are published data assessing differences in mistreatment within the medical environment based on student race-ethnicity, to our knowledge there are no reports exploring professionalism in such a manner. The data pertaining to mistreatment are revealing in that they do show that learner race-ethnicity and gender color the perception of mistreatment, with all studies demonstrating higher perceptions or frequency of mistreatment in non-Caucasian students. Non-Caucasian 3rd year medical students, in one study, perceived receiving less favorable treatment in almost all their rotations, although the extent of this varied based on the specific clinical setting.4 In another study, among 4th year medical students, a higher frequency of mistreatment and harassment was

Corresponding author: Lavjay Butani, MD, Department of Pediatrics, University of California Davis Medical Center, Ticon 2, Room 348, 2516 Stockton Boulevard, Sacramento, CA 95817 USA; Tel: +1 916-734-8118; Fax: +1 916-734-0629; email: [email protected]


reported by Native-American and Hispanic students with the lowest frequency being reported by African-American students, further supporting the observation that non-Caucasian students have different perceptions of the clinical environment as compared to Caucasian students.5 We conducted our study to attempt to bridge this gap. The specific objectives of our study were to explore race-ethnic differences in a) what medical students perceive to be optimal strategies for instruction on professionalism, and b) the frequency and types of self-reported unprofessional and superlative professional experiences which medical students were subjected to and their impact. Our hypothesis was that students from minority ethnic backgrounds would have a differing view on how professionalism is construed in the medical environment and would report higher and different types of unprofessional behaviors, witnessed and/or experienced.

Methods This was a mixed-methods study, using quantitative and qualitative data obtained from a survey developed for the purposes of a larger study evaluating professionalism at a public medical school on the West Coast. The aim of the survey was to identify ideal strategies for teaching professionalism, as well as student experiences of unprofessional and exceptionally professional behaviors. No definition of professionalism was provided. Respondents were asked to state (and describe) if a) they witnessed unprofessional behaviors among faculty, staff, the school administration, or b) students, c) they felt they were unfairly evaluated or d) unfairly treated by faculty, staff, or the administration, and e) faculty, staff, or the administration exceeded their professional expectations. An additional question explored whether respondents felt that the unprofessional behaviors or unfair treatment/evaluation had negatively impacted their final grade. Demographic information collected included respondent gender and race-ethnicity, categorized as follows: African American/Black, American Indian/Alaskan, Chinese-American/Chinese, Latino/Hispanic, Other Asian, and White/Caucasian. These categories were determined based on the most prevalent ethnicities among students at our school. The survey was anonymous and was administered online via Survey Monkey (Palo Alto, California) between August and November 2010. An email containing the link to the survey was sent to all

eligible students, followed by two reminders. The survey was closed when no new responses had been received for one week. It was felt that students who had successfully completed at least one full year would have had sufficient experience of the school learning climate and therefore all medical students enrolled in the 2nd through 4th year at our school (N = 331) were eligible to participate. Participation was voluntary. Informed consent was implied by completion of the survey by respondents. The study protocol was reviewed and approved by the Institutional Review Board. At the time of this study, there was no formal faculty training in professionalism. Formal curricula on professional attributes for students are addressed in longitudinal ‘doctoring’ sessions and pertain to issues such as culturally responsive care, adherence to ethical principles, and skills in addressing value conflicts. These are taught using formal presentations, small group discussions, and simulated patient encounters. For the purpose of the current study, only data pertaining to the survey questions related to our aims were analyzed. For the qualitative analysis, two investigators (ALS and LB) independently reviewed survey responses to the questions regarding professional and unprofessional behaviors, with respondent gender and race-ethnicity removed, and categorized responses into one of five themes based on a pre-determined, existing framework of medical professionalism.6 These themes were as follows: adherence to ethical principles; effective interactions with patients and families (coded as patient interactions); effective interactions with others in the health care system (coded as team interactions); reliability; and commitment to continuous improvement of self and others. One of the coders was female and the other male; race-ethnicity was Caucasian and Asian. Both coders are educators in the medical school and very familiar with the learning environment. Differences in coding were reconciled by consensus during a face to face discussion session between the two coders. If multiple unprofessional or exceptionally professional behaviors were reported by a single respondent, each behavior was coded separately into a theme. A single behavior was categorized only into a single theme based on the best match. After this step was completed, respondent gender and race-ethnicity were reintroduced, in order to explore any group differences across thematic categories.


Statistical analyses used SAS Version 9.3 (SAS Institute, 2002-2010, Carey, NC) to summarize the survey responses as frequencies (percentages), both overall and stratified by gender and race-ethnicity. Group differences (across gender and race-ethnicity) were evaluated using Fisher’s exact tests for the frequencies of the options chosen, and exact two sample Wilcoxon tests for the number of the behaviors of interest reported for each of the open ended questions. All tests were two-tailed, with α = 0.05.

Results Respondent characteristics: Of the 331 students who received the survey, 114 (34%) responded. Four students did not disclose their gender. Among those who did, 73 (66%) were

female and 37 (34%) were male. Of the 108 respondents who reported their race-ethnicity, 59 (55%) were Caucasian, 23 (22%) were Asian American, 5 (5%) were African American, 11 (10%) were Latino/Hispanic, and 10 (9%) were of other ethnic backgrounds, including mixed race and Middle Eastern. There were no statistically significant differences in gender and race-ethnicity between respondents and non-respondents; 60% of the eligible population was female and 50% were Caucasian (Fischer’s exact test p-value = 0.4 for ethnicity and p-value = 0.3 for gender). For the purpose of data analyses, due to the limitations in sample size, race-ethnicities were merged into two categories: Caucasian (comprising the White/Caucasian group) and non-Caucasian (comprising all the others).

Gender1 Ethnicity2

Overall n = 114

Female n = 73

Male n = 37

Caucasian n = 59

Not Caucasian n = 49

Have you received any teaching on professionalism so far during medical school?

None at all 3 (3%) 2 (3%) 1 (3%) 0 (0%) 3 (6%)

Minimal 61 (54%) 39 (53%) 21 (57%) 33 (56%) 25 (51%)

About right 36 (32%) 23 (32%) 11 (30%) 20 (34%) 13 (27%)

Too much 14 (12%) 9 (12%) 4 (11%) 6 (10%) 8 (16%)

In your opinion, what constitutes an effective strategy for teaching professionalism? (check all that apply)

Lectures 25 (22%) 18 (25%) 7 (19%) 13 (22%) 10 (20%)

Small group 52 (46%) 36 (49%) 15 (41%) 28 (47%) 22 (45%)

Faculty role models 99 (87%) 63 (86%) 32 (86%) 53 (90%) 40 (82%)

Peer role models 69 (61%) 51 (70%)* 16 (43%)* 43 (73%)† 21 (43%)†

Other 17 (15%) 8 (11%) 8 (22%) 5 (8%) 11 (22%)

Table 1: Respondent opinion towards teaching of professionalism 1 Gender is missing for 4 participants, 2 Ethnicity is missing for 6 participants, Due to rounding, percentages do not add to 100% . *† Women and Caucasian students considered peer role models significantly more effective in teaching professionalism than men and non-Caucasian students, respectively (Fisher’s exact test p-values < 0.05).

Teaching of professionalism: As shown in Table 1, over half of the respondents (57%) felt that they had received minimal or no teaching regarding professionalism, with no gender or race-ethnic differences in this perception. A large majority of respondents (87%) reported faculty role models to be effective teachers of professionalism, followed by peer role models (61%). The ‘other’ category of teaching strategies included: upbringing, readings, provision of effective feedback, and creating a

culture that promotes accountability (including public disciplining of unprofessional behaviors), “roots out fear” and promotes humanism (including being treated with respect and as colleagues). Subgroup analyses revealed that, when compared to male (43%) and non-Caucasian (43%) respondents respectively, significantly more females (70%) and Caucasians (73%) found peer role models to be effective teachers of professionalism (Fisher’s exact test p-values = 0.01 and 0.002, respectively). There


were no other statistically significant differences by gender or race-ethnicity of respondents. Experiences of professional and unprofessional behaviors: While there were no significant gender differences for any of the questions exploring experiences of professional and unprofessional behaviors (see Table 2), several race-ethnic differences were noted. Compared to Caucasian respondents, non-Caucasians more often reported situations in which they felt that faculty, staff, or administration had unfairly evaluated them (49% versus 39%) and unfairly treated them (27% versus 17%), although these differences did not reach statistical significance. Non-Caucasian students also reported witnessing significantly more frequent unprofessional behaviors among faculty, staff or administration than Caucasian students (55% versus 39%, Fisher’s exact test p-value = 0.03). A greater percentage of non-Caucasian students (69%) compared to Caucasian respondents (54%) were either unsure of or felt that the aforementioned interactions (unfair evaluations, unfair treatment, and/or unprofessional behaviors) negatively affected their grade (Fisher’s exact test p-value = 0.20). There were no significant differences in the percentage of respondents reporting unprofessional behaviors among their peers or in the percentage of respondents reporting superlative behaviors, by respondent gender or ethnicity. Post-hoc subset analyses: Since Asians were the 2nd largest race-ethnic group after Caucasians, we performed post-hoc analyses for the 2 questions where ethnic differences were noted, analyzing Asians as a separate category. For the question related to teaching professionalism, the Asian students most closely resembled the non-Caucasian students: 43.5% reported peer-role models to be an effective teaching strategy (p- values = 0.01 for Caucasian versus non-Caucasian/non-Asian and 0.02 for Caucasian versus Asian). On the other hand, for the question on whether they had witnessed unprofessional behaviors among faculty, staff or administration, the Asian cohort resembled the Caucasians-39% answered in the affirmative (p-values = 0.004 for Caucasian versus non-Caucasian/non-Asian and 0.05 for Asian versus non-Caucasian/non-Asian). Qualitative analyses: Of the 50 (44%) students reporting unprofessional behaviors among faculty, staff, or administration, one did not provide enough details to allow thematic classification. Seventy-eight narratives of unprofessional behaviors among faculty, staff, or administration were reported, yielding a mean of 1.6 narratives per respondent

(range 1-7). Ten (13%) responses were categorized as ethical issues, 25 (32%) referred to patient interactions, 35 (45%) pertained to team interactions, 6 (8%) were examples of lack of reliability, and 2 (3%) described lack of commitment to continuous improvement. An example from the most commonly cited thematic category (team interactions) was as follows: “I have seen faculty and other physicians talk unkindly about specific branches of medicine like primary care (specifically pediatrics, family, and psychiatry). I think this is very unprofessional when everyone needs to be working together to provide the best care.” Of the 35 narratives regarding unprofessional team interaction, only 9 could be clearly ascertained as describing an incident where the author was directly targeted; the other 26 referred to interactions witnessed by students or were written in third person. Of note, 36 (72%) of the 50 students who reported episodes of unprofessional behavior among staff, faculty, or administration had also responded affirmatively to one or both of two other questions (having been unfairly treated or unfairly evaluated). With respect to unprofessional behaviors demonstrated by students, 45 (39%) respondents described 68 behaviors (mean of 1.5 narratives per respondent, range 1 to 4). Of these, 31 (46%) were categorized as ethical issues, 4 (6%) referred to patient interactions, 16 (24%) involved team interactions, 16 (24%) illustrated lack of reliability and 1 (1%) showed a lack of commitment to continuous improvement. The most common thematic category, unlike for the previous question, pertained to ethical issues. Representative examples include: “I know of several students who go to work stoned,” and “Three students on one team all being in cahoots and telling their resident that they had a class obligation, when in fact they did not and lied to get off of service.” Thirty three (73%) of the 45 students who responded affirmatively to this questions had also provided examples of unprofessional behavior among faculty, staff, and school administration. Forty-four (39%) respondents reported instances when faculty, staff or administrators exceeded their expectations; four did not provide enough information to allow thematic classification. This yielded a total of 56 narratives (mean of 1.4 per respondent, range 1 to 4). The narratives were classified as follows: 4 (7%) were ethical issues, 7 (13%) patient interactions, 15 (27%) team interactions, 5 (9%) reliability, and 25 (45%) commitment to continuous improvement. Most examples from the last thematic category, which


was also the most frequently reported, pertained to commitment of faculty and residents to teach and support students, such as “Many of the small groups and faculty lecturers have gone out of their way to help us understand the material and be

available to us for questions,” and “Some of the interns have been surprisingly helpful on many rotations, checking in to see how the medical students are doing in spite of being very busy themselves.”

Gender1 Ethnicity2

Overall (n = 114)

Female (n = 73)

Male (n = 37)

Caucasian (n = 59)

Non-Caucasian3 (n = 49)

Any situations in which you felt like the faculty, staff, or administration unfairly evaluated you?

Yes 49 (43%) 29 (40%) 18 (49%) 23 (39%) 24 (49%)

No 65 (57%) 44 (60%) 19 (51%) 36 (61%) 25 (51%)

Any situations in which you felt like the faculty, staff, or administration treated you unfairly?

Yes 26 (23%) 14 (19%) 10 (27%) 10 (17%) 13 (27%)

No 88 (77%) 59 (81%) 27 (73%) 49 (83%) 36 (73%)

Any examples of unprofessional behavior you have witnessed among faculty, staff, or administration?

Yes 50 (44%) 31 (42%) 17 (46%) 20 (39%)* 27 (55%)*

No 64 (56%) 42 (58%) 20 (54%) 39 (66%) 22 (45%)

“Yes” to any of the above 3 questions?

Yes 72 (63%) 46 (63%) 24 (66%) 33 (56%) 36 (73%)

No 42 (37%) 27 (37%) 13 (35%) 26 (44%) 13 (27%)

If answered yes to any of the above, do you feel that this situation(s) negatively impacted your final grade?2

Yes 37 (56%) 23 (56%) 12 (52%) 14 (45%) 20 (63%)

No 25 (38%) 16 (39%) 9 (39%) 15 (48%) 10 (31%)

Not Sure 4 (6%) 2 (5%) 2 (9%) 2 (9%) 2 (6%)

Any examples of unprofessional behavior you have witnessed among students?

Yes 45 (39%) 27 (37%) 16 (43%) 24 (41%) 17 (35%)

No 69 (61%) 46 (63%) 21 (57%) 35 (59%) 32 (65%)

Any situations in which you felt like the faculty, staff, or administration exceeded your expectations?

Yes 44 (39%) 25 (34%) 17 (46%) 19 (32%) 22 (45%)

No 70 (61%) 48 (66%) 20 (54%) 40 (68%) 27 (55%)

Table 2: Summary of survey responses. 1 Answers are missing for 4 participants; 2 Answers are missing for 6 participants 3 Non-Caucasian includes African American, Asian American, Latino/Hispanic, and Other * Non-Caucasian students reported significantly more faculty/staff/administration unprofessional behavior than Caucasian students (Fisher’s exact test p-value = 0.03).


Themes and frequency of narratives − comparison by gender and ethnicity: Among respondents who described unprofessional behaviors among faculty, staff, or administration, the number of narratives per respondent was not significantly different either with respect to race-ethnicity (mean and standard deviation of 1.4 and 0.6 for Caucasians respectively, versus 1.8 and 1.5 for non-Caucasians, Wilcoxon exact test p = 0.79) or gender (mean and standard deviation 1.8 and 1.4 for women respectively, versus 1.2 and 0.4 respectively for men, Wilcoxon exact test p = 0.19). Summaries of thematic categories stratified by ethnicity and gender are depicted in Table 3. Narratives from men and women fell into similar thematic categories. Narratives authored by Caucasian students more frequently addressed unprofessional behaviors related to ethical values, whereas those reported by non-Caucasians more often described behaviors pertaining to patient and team interactions. When we examined the race-ethnicity of the authors of the 9 narratives where students were the direct targets of the unprofessional team behaviors, responses came from 8 students. Among those 8 students, 5 were women and 6 were non-Caucasian. Similarly, with respect to descriptions of unprofessional behaviors witnessed among peers, the number of narratives per respondent was not significantly different either with respect to race-ethnicity or gender of the respondent. Even for this question, narratives written by Caucasian respondents more frequently described unprofessional behaviors related to ethical values, while those reported by non-Caucasian students more often focused on behaviors pertaining to patient and team interactions. There were no significant gender or race-ethnicity differences in the number of narratives per-respondent with regard to reported behaviors that exceeded expectations. Narrative thematic categories were similar for all sub-groups.

Discussion The aim of our study was to investigate race-ethnic differences in opinions about professionalism teaching as well as to explore student experiences of unprofessional and exemplary behavior. Non-Caucasian students’ opinions of effective teaching strategies and reports of unprofessional experiences were different than those of Caucasian students, showing that students of different backgrounds perceive or experience the learning environment differently. Non-Caucasian students reported having witnessed significantly more frequent

unprofessional behavior among faculty, staff, or peers compared to their Caucasian colleagues. This may be due to cultural differences in what is perceived as unprofessional behavior, the result of minority students being more perceptive or having a lower threshold for interpreting observed behaviors as being unprofessional, or due to unconscious bias (bias that one is not entirely aware of) among faculty or residents. It is important to understand the reasons why non-Caucasian students had different subjective experiences and the impact these negative experiences may have on professional identity formation. In our study, minority students and women were the direct targets of unprofessional team interactions slightly more often than Caucasian students and men, respectively. Situational power has been shown to enhance unconscious racial bias, which could cause team members to treat non-Caucasian students differently, even though all students are subjected to a power differential throughout the medical school years.7 Previous studies have found that minority medical students were significantly more likely than Caucasian students to report that their race-ethnicity negatively affected their educational experience.8,9 Moreover, minority students who reported such experiences had higher burnout, depressive symptoms, and a lower mental quality of life compared to minority students without these experiences.8 Looking at it from a different perspective, individuals who are burned out, anxious or depressed may have a more negative perception of their environment, along with a heightened vulnerability to insensitive remarks and may therefore interpret certain events differently.10 In the present survey, students reporting negative team interactions were the target of the unprofessional behaviors in about a quarter of the situations reported, showing that perceptions of a suboptimal learning climate extend beyond one’s personal interaction sphere. Further exploration of the medical learning environment is warranted, with attention to potential manifestations of gender or racial unconscious bias. Social and personality psychologists have contributed a significant body of work to the understanding of interpersonal perception. For example, the person model is a theoretical model that explains how an individual (perceiver) forms an impression of another individual (target), based on six variables: personality (P), error (E), residual (R), stereotype (S), opinion (O), and norm (N). Of those, P and, in some contexts, O and N, represent accuracy, whereas S, R, and E represent bias.11


Relationship variance (the extent to which perceivers uniquely rate a particular target), accounts for approximately 20% of the variance in perceptions of others and tends to be larger than the variance due to unique characteristics of the target.12 Also, variances due to intrinsic target and perceiver characteristics may be higher in cross-cultural judgments, due to existing stereotypes.11 In

our study, over two thirds of students who reported unprofessional behavior among those in power also felt they had been unfairly treated or unfairly evaluated at some point. Thus, previous negative experiences may have led to persistent affective biases regarding authority figures, contributing to perceptions of unprofessional behavior on the part of these groups.13

All Gender Ethnicity

Female Male Caucasian Non-Caucasian

Examples of unprofessional behavior witnessed among faculty, staff, or administration (n = 78 classifiable narratives reported by 49 students1)

Ethical principles 10 (13%) 7 (13%) 3 (14%) 7 (25%) 3 (6%)

Patient interactions 25 (32%) 18 (32%) 6 (29%) 6 (21%) 18 (38%)

Team interactions 35 (45%) 25 (45%) 10 (48%) 11 (39%) 23 (48%)

Reliability 6 (8%) 5 (9%) 1 (5%) 2 (7%) 4 (8%)

Continuous improvement 2 (3%) 1 (2%) 1 (5%) 2 (7%) 0 (0%)

Examples of unprofessional behavior witnessed among students (n = 68 classifiable narratives reported by 45 students2)




Reliability 16 (24%) 11 (28%) 5 (19%) 9 (24%) 6 (24%)


Situations in which faculty, staff, or administration exceeded expectations (n = 56 classifiable narratives reported by 40 students3)




Reliability 5 (9%) 5 (13%) 0 (0%) 3 (12%) 2 (7%)


Table 3: Professional and unprofessional behaviors: thematic categories. Non-Caucasian includes African American, Asian American, Latino/Hispanic, and Other. 1 One respondent did not give enough details to allow thematic classification. Gender missing for 1 respondent; ethnicity missing for 2 respondents. 2 Gender missing for 2 respondents; ethnicity missing for 4 respondents. 3 Four respondents did not give enough details to allow thematic classification. Gender missing for 2 respondents; ethnicity missing for 3 respondents.


The fact that non-Caucasian respondents in the present survey viewed the learning climate in a more negative light is aligned with studies of the work force beyond health care. For instance, in a survey of 2,686 employees of an electronics company, Caucasian men perceived the organization as more fair and inclusive than did Caucasian women and racial/ethnic minority men and women.14 Also, among the 3,400 employees in a high-tech company, women and members of racial/ethnic minorities were more likely to feel excluded from critical organizational processes. Feeling excluded was linked to job dissatisfaction and a lower sense of well-being.15 Cultural mistrust, the inclination of racial/ethnic minority members to mistrust Caucasians, has been identified in health care, politics, business and educational settings of all levels.16 Roquemore and Laszloffy describe this phenomenon as follows: “during cross-racial interactions, black people have an invisible antenna that scans the interaction for signs of being negatively viewed and treated by white people.”17 In minority medical students, cultural mistrust may be enhanced by general feelings of powerlessness and lack of control.18,19 This combination of factors might cause non-Caucasian students to be more vigilant and be more acutely aware of interpersonal tensions. It is also possible that minority students, who have worked extremely hard to overcome more obstacles than some Caucasian students in order to enter medical school, may have higher expectations of professional behavior from those around them.20 Interestingly, students were the source of unprofessional behaviors (reported by 39% of students) almost as often as individuals in authority positions (reported by 44% of respondents). These results highlight the influence of the hidden curriculum and the impact of unprofessional behavior by those in power on students’ professional identity formation. Students might model behaviors they observe, whether unprofessional or exemplary. With regard to faculty and staff behaviors which exceeded expectations, themes distilled from the present survey responses aligned with those described by Curry and colleagues and included team work, interactions with patients, and commitment to students’ education.21 A large majority of respondents in the present survey viewed faculty role models as effective teachers of professionalism. However, non-Caucasian students were significantly less likely than Caucasians to cite peer models as being helpful in this regard. This could be because of the low overall number of students in each ethnic minority

group. Minority students (especially Black men) may feel isolated because of small numbers of colleagues of similar race and of the scarcity of role models.20 Even though academic institutions have made great strides in increasing the diversity of medical students, resident and faculty demographics have not caught up with this trend. At the medical school where this study took place, 51% of residents and fellows were Caucasian, and 52% were women when this study was conducted. Among faculty, 32% were women and 69% were Caucasian in July 2010. However the detailed race-ethnicity profile of trainees and faculty was not obtained as part of this study, so it is difficult to compare to student demographics. A statistically significant gender difference was uncovered in this study- more women than men felt that peer role models were effective in teaching professionalism. Female students build strong support networks during medical school years, which is why peer feedback may be viewed as more relevant.22 Women faculty peer mentoring groups have also helped improve the overall climate.23 The present study has several limitations. We did not use a previously validated instrument but built an original survey for the purposes of this study. Surveys reveal the respondents’ subjective interpretations of their experiences and opinions. Students who had been the victims of unprofessional or unfair treatment may have been more likely to respond to this survey. No definition of professionalism was included in the survey, so respondents were free to interpret the questions according to their own experience. It is possible that students who reported having felt unfairly evaluated or unfairly treated were more prone to answering the next questions affirmatively, regarding examples of unprofessional experiences. We attempted to minimize subjectivity by asking for concrete examples of unprofessional behavior. Several students did not feel comfortable describing their specific situations, but intimated they had encountered such behaviors. Data regarding the setting and timing of unprofessional behaviors reported were not collected in order to minimize the likelihood of identifying those involved and thus promote greater candor among respondents. Also due to the limited sample size non-Caucasian students may have been less likely to respond to the survey due to fear of being identified. Thus, no inferences can be made with regard to associations of specific learning environments with a higher frequency of unprofessional behavior. Larger, multi-institutional studies may help explore professionalism lapses in relationship to particular


settings, work hours, and other variables. Larger sample sizes would also allow exploration of the interaction of gender and race-ethnicity bias. Lastly, since the present study took place at one U.S. medical school, the generalizability of findings to other institutions is not entirely clear.

Acknowledgements The authors thank Darin Latimore, MD, Assistant Dean for Student and Resident Diversity at the University of California Davis School of Medicine for his valuable feedback on the survey and providing resident/fellow demographic data; Terri Madderra and Kathleen MacColl for providing faculty demographic data; the Department of Psychiatry and Behavioral Sciences for providing funding for Dr. Iosif’s time; and the UC Davis School of Medicine Dean's Office and the Betty Irene Moore School of Nursing for supporting Dr. Seritan’s time on this study. We also thank Ioana Seritan for her helpful editorial suggestions.

Notes on Contributors LAVJAY BUTANI, MD, is Professor and Co-Director of the Pediatric Clerkship, Department of Pediatrics, University of California Davis Medical Center, Sacramento, CA, USA. ANA-MARIA IOSIF, PhD, is Assistant Adjunct Professor, Departments of Public Health Sciences in the Division of Biostatistics, University of California Davis Medical Center, Sacramento, CA, USA. ALYN KELLEY, MD, is Resident, Department of Internal Medicine, University of California Davis Medical Center, Sacramento, CA, USA. OMAR WASHINGTON, MD, is Resident, Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA. ANDREEA L. SERITAN, MD, is Associate Professor, Department of Psychiatry and Behavioral Sciences and Assistant Dean of Student Wellness, University of California Davis Medical Center, Sacramento, CA, USA.

Keywords Ethnicity, Learning climate, Mistreatment, Professionalism, Race


References 1. Hafferty F. W. Beyond curriculum reform:

confronting medicine's hidden curriculum. Acad Med. 1998;73:403-7.

2. Park J., Woodrow S. I., Reznick R. K., Beales J., MacRae H. M. Observation, reflection, and reinforcement: surgery faculty members' and residents' perceptions of how they learned professionalism. Acad Med. 2010;85:134-9.

3. Al-Eraky M. M., Chandratilake M. How medical professionalism is conceptualised in Arabian context: a validation study. Med Teach. 2012;34 Suppl 1:S90-5.

4. Richardson D. A., Becker M., Frank R. R., Sokol R. J. Assessing medical students' perceptions of mistreatment in their second and third years. Acad Med. 1997;72:728-30.

5. Woolley D. C., Paolo A. M., Bonaminio G. A., Moser S. E. Student treatment on clerkships based on their specialty interests. Teach Learn Med. 2006;18:237-43.

6. Wilkinson T. J., Wade W. B., Knock L. D. A blueprint to assess professionalism: results of a systematic review. Acad Med. 2009;84:551-8.

7. Richeson J. A., Ambady N. Effects of situational power on automatic racial prejudice. J Exp Soc Psychol. 2003;39:177-83.

8. Dyrbye L. N., Thomas M. R., Eacker A., Harper W., Massie F. S., Jr., Power D. V., Huschka M., Novotny P. J., Sloan J. A., Shanafelt T. D. Race, ethnicity, and medical student well-being in the United States. Arch Intern Med. 2007;167:2103-9.

9. Strayhorn G., Frierson H. Assessing correlations between black and white students' perceptions of the medical school learning environment, their academic performances, and their well-being. Acad Med. 1989;64:468-73.

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12. Mohr C., Kenny D. The how and why of disagreement among perceivers: An exploration of person models. J Exp Soc Psychol. 2006;42:337-49.

13. Pichon S., Rieger S. W., Vuilleumier P. Persistent affective biases in human amygdala response following implicit priming with negative emotion concepts. Neuroimage. 2012;62:1610-21.

14. Barak M. E. M., Cherin D. A., Berkman S. Organizational and personal dimensions in diversity climate. J Appl Behav Sci. 1998;34:82-104.

15. Barak M. E. M., Levin A. Outside of the corporate mainstream and excluded from the work community: a study of diversity, job satisfaction and well-being. Community Work & Family. 2002;5:133-57.

16. Phelps R. E., Taylor J. D., Gerard P. A. Cultural mistrust, ethnic identity, racial identity, and self-esteem among ethnically diverse Black university students. J Counseling Development. 2001;79:209-16.

17. Roquemore K. A., Laszloffy T. The Black Academic's Guide to Winning Tenure − Without Losing Your Soul. In: Roquemore KA, Laszloffy T, editors. The Black Academic's Guide to Winning Tenure − Without Losing Your Soul. London, UK: Lynne Rienner Publishers, Inc; 2008. p. 11-29.

18. Mirowsky J., Ross C. E. Paranoia and the structure of powerlessness. Am Sociol Rev. 1983;48:228-39.

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23. Seritan A. L., Bhangoo R., Garma S., Dube J., Park J. H., Hales R. Society for women in academic psychiatry: a peer mentoring approach. Acad Psychiatry. 2007;31:363-6.




ORIGINAL RESEARCH

Research-Tutored Learning: An Effective Way for Students to Benefit Research by Critical

Appraisal

Vincent T. Janmaat, Kim E. Kortekaas, Thomas M. Moerland,

Mayke W.C. Vereijken, Jan W. Schoones, Astrid van Hylckama Vlieg &

Friedo W. Dekker Leiden University Medical Center, Leiden, The Netherlands

Abstract Introduction: Medical students must be able to read and critically appraise scientific papers. Therefore, they have to be taught specific skills. There is evidence from a range of studies that research-tutored learning is an effective way to achieve this. We examined the learning gain and opinion of students exposed to research-tutored education. Methods: Two hundred fifty-five medical students from the Leiden University Medical Center reviewed the quality of 144 randomized controlled trials appearing as references in 59 advertisements published in both an independent scientific and a commercial medical journal. We examined the subjective learning gain and critical appraisal skills of students by a questionnaire. Results: The assessments of references showed that in both a commercial and an independent medical journal 70-80% of included references scored suboptimal. The opinion of students about this course was positive. Furthermore, after being exposed to research-tutored learning, students rated their critical appraisal skills as having improved (3.86 mean, SD 0.88 on a scale of one to five). They also indicated an understanding of the importance of reading literature during their career. Conclusions: Exposing students to research-tutored learning is an effective way to develop additional skills concerning reading and critical appraisal of scientific papers.

Introduction Medical information comes from many sources, including advertisements in medical journals from pharmaceutical companies. These advertisements are an important source of information for general practitioners.1 However, it has been shown that many claims in such advertisements are not sufficiently evidence-based when the cited references are verified.2-8 It is therefore essential that medical students learn to judge the presented information and separate reliable from non-reliable advertisements. In addition, they should be able to communicate and discuss this information with colleagues. Consequently, medical students must be able to read and critically appraise scientific papers and be able to present their own scientific findings. All this requires a specific additional set of skills.

Healey suggests that research-tutored learning which focuses on writing and discussing papers or essays, is one of the most effective ways to develop this additional set of skills.9 There is clear evidence for this from a range of studies that evaluate learning in a research-tutored environment.10 Hence, students are likely to gain most benefit from research, in depth of learning and understanding, if they participate in research activities.11 Students experiencing research feel that they gain intellectuality, are exposed to professional socialization, gain technical and communication skills, and are more certain in their educational and career plans.12 This is illustrated by the fact that students participating in the ‘research’ Scholarly Concentration at the USF Health Morsani College of Medicine, showed a concordance of 70% between the chosen area of research and the choice of residency.13 However, it remains unclear whether research-tutored learning also affects self-efficacy with respect to critical appraisal skills of students.

Corresponding author: Friedo W. Dekker, PhD, Department of Clinical Epidemiology, Leiden University Medical Center, PO box 9600, 2300 RC Leiden, The Netherlands. Tel: +31 (0)71 526 2183/5230; e-mail: [email protected]


In this study we aim to examine students’ satisfaction and perceived learning outcomes of our new approach to research-tutored learning. We focus on self-efficacy, the measure of one's own ability to complete tasks and reach goals. For medical students it is not enough to have the knowledge and the skills to perform a task, they must also have the conviction that they can successfully perform it. According to Bandura, self-efficacy beliefs lie at the core of human functioning.14 Additionally, it has been shown that self-efficacy has a direct positive effect on performance in specific medical contexts.15 We

therefore examined the impact of research-tutored learning in a cohort of 255 pre-clinical medical students of Leiden University, the Netherlands. During the research-tutored teaching program, medical students reviewed the quality of randomized controlled trials (RCTs) appearing as references in advertisements in both an independent scientific and a commercial medical journal. Afterwards, the opinion of the students about research-tutored learning and their perceived learning outcomes was examined by a questionnaire.

Table 1: The validity of RCT references in advertisements of H&W compared to MM as scored by 255 medical students. *H&W = Huisarts en Wetenschap. †MM = Modern Medicine. ‡Questions based on the Delphi list. 14 The answer options ‘yes’, ‘don’t know’, and ‘no’ were assigned question scores of 2, 1, and 0 point(s) respectively.

Methods In the Leiden University Medical Center (LUMC), 255 second year medical students are required to enroll in the course Scientific Education. The course focuses on several specific scientific skills and forms the foundation for scientific thinking and acting in the LUMC medical curriculum. It offers training in different study-designs and the basics of statistical data analysis. During this course, we have exposed students to research-tutored learning. To this end the students reviewed the quality of RCTs appearing as references in advertisements in both an independent scientific and a commercial medical journal.

These advertisements were collected from two Dutch journals aimed at general practitioners: Huisarts en Wetenschap, and Modern Medicine, because the content of these journals is relatively well understood by second year medical students. From the available journals aimed at general practitioners, we chose two journals with a large printing run. Therefore, these journals have a high impact on prescribing behavior in the Netherlands. Huisarts en Wetenschap (ISSN 0018-7070) is the official journal of the Dutch College for General Practitioners (NHG) published by Springer Publishers. The goal of the NHG is to support evidence-based patient care. Huisarts en Wetenschap is a peer reviewed, scientific journal.16

H&W* (n=69)

MM† (n=44)

Difference [95% CI]

Mean reference validity score 13.34 14.36 -1.03 [-2.02 to -0.41]

Mean question score‡

1) Was a method of randomization performed? 1.98 1.96 0.02 [-0.04 to 0.08]

2) Was the treatment allocation concealed? 1.16 1.26 0.10 [-0.29 to 0.08]

3) Were the groups similar at baseline regarding the most important prognostic indicators?

1.75 1.83 -0.08 [-0.21 to 0.04]

4) Were eligibility criteria specified? 1.83 1.91 -0.08 [-0.02 to 0.04]

5) Was the outcome assessor blinded? 1.04 1.30 -0.26 [-0.48 to -0.04]

6) Was the care provider blinded? 1.21 1.46 -0.25 [-0.53 to 0.03]

7) Was the patient blinded? 1.32 1.62 -0.29 [-0.59 to 0.01]

8) Were point estimates and measures of variability presented for the primary outcome measures?

1.47 1.49 -0.02 [-0.23 to 0.19]

9) Did the analysis include an intention-to-treat analysis? 1.57 1.53 0.03 [-0.18 to 0.25]


Modern Medicine (Dutch edition, ISSN 0929-0141) is published by Van Zuiden Communications, and it is freely distributed among all Dutch general practitioners. Its goal is to inform the reader about the latest developments in patient care in an accessible manner.17 Because of its goal and because it is not peer reviewed it is considered to be a commercial journal. All drug-promoting advertisements that appeared in these journals were copied: Huisarts en Wetenschap, January to December 2005; and Modern Medicine, January to December 2007. From all advertisements, the listed references were obtained using PubMed (http://www.ncbi.nlm.nih.gov/pubmed/). This database was chosen because both students and general practitioners use this database most frequently and since this database is most extensive and up to date. We chose to specifically study RCTs, since they provide a high level of evidence and are highly prevalent in pharmaceutical advertisements. Each student reviewed the quality of two RCTs. These were independently assigned to each student and students were blinded for the origin of their references. In order to promote critical appraisal of the reference and minimize inter-observer variation the students used a standardized score form containing nine questions. They received a manual with exact guidelines on how to score every question, based on the Delphi list (see Table 1 for the questions contained in the score form).18 The students were trained to use this score form during a one-hour theoretical lecture. During this lecture issues concerning the reliability of RCTs, such as randomization, treatment allocation, and blinding were discussed. The students also reviewed and discussed a non-related RCT as an exercise in critical appraisal in a small group setting. Additionally, all students had to present both of their critically appraised RCTs in a group meeting with colleagues and a supervisor of the department of Communication in Science. This ensured that students took their assignments seriously. Before this time, the conventions, rules and principles underlying an effective presentation in an academic setting were introduced, and individual feedback on a student’s own performance was provided. In this manner a presentation skills training was integrated into the course. Finally, open-ended questions were included in the score form, requesting an explanation of the reasoning behind the chosen answer. Students were required to fill out their score forms in order to receive their course end mark.

Score form questions could be answered by (a) yes, (b) don’t know, or (c) no. Yes denoted the presence of the desired characteristic, don’t know indicated mentioning of the characteristic with lack of specification, and no denoted the characteristic to be absent or not mentioned. Yes, don’t know, and no were assigned scores of two, one, and zero point(s) respectively. Each reference was planned to be evaluated by four different students. A mean question score was then calculated per question, per reference. For every reference a ‘reference validity score’ was calculated, that is the sum of the mean question scores of all nine questions for a single reference (range zero to 18 points). We considered a study suboptimal if the mean reference validity score was below 16 points.19 In this case, more than three out of nine questions were scored suboptimal, or more than one question was scored with no points at all and a second question was scored suboptimal. Score forms were submitted via the internet using a web design interface and were automatically entered into an SPSS database (version 16.0) for statistical analysis (IBM Corporation, Armonk, NY). When the difference between the highest and lowest reference validity score was more than five points, the most deviant result was deleted from the database. When the database contained less than three evaluations of a single reference, a panel of four experienced students reassessed it. Every RCT reference was grouped into one of the following drug categories: (a) cardiovascular, (b) pulmonary, (c) diabetic, and (d) other (Table 2). In order to assess the effect of this specific type of research-tutored education, all 255 students were asked to fill out a questionnaire in which a scoring system of one to five was used. One represented total disagreement with the given statement and five represented total agreement. The questionnaire was designed to give insight in the students’ satisfaction with regard to the course and to collect the students’ self-assessment data. The students were asked amongst others about how valuable the course was for their intellectual and learning process, if the course was challenging, and if they had learned to read articles more critically (Table 3, see Appendix).


Table 2: Mean reference validity scores* by drug category *Mean reference validity scores calculated from separate reference validity scores based on the questions as shown in Table 1.

Results To gain insight in the students’ satisfaction with the course and to collect self-assessment data, we analyzed the outcome of the questionnaire (Table 3). Results show that the research-tutored learning gain as implemented in our course was rated positive (3.14 mean, SD 0.86). The learning curve was rated with a mean of 3.07 (SD 0.86). Students reported their presentation skills to be improved (3.75 mean, SD 0.88). The feedback at their presentation was rated as good (3.84 mean, SD 0.81). The amount of independent work was considered average by the students (2.93 mean, SD 1.00). Students could not relate the assignments presented to them in the course with aspects they thought they would encounter in their future careers (mean 2.53, SD 1.06). The assessments of the RCTs were rated educational at 3.48 (SD 1.03) and students rated their critical appraisal skills as improved (3.86 mean, SD 0.88). The importance of scientific skills for clinicians was clear to the students (3.88 mean, SD 0.80) and the course contributed to this opinion (3.71 mean, SD 0.91). The results we found regarding the quality of RCTs appearing as references in advertisements in both an independent scientific and a commercial medical journal are secondary and incidental to our findings regarding learning gain and the opinion of students about research-tutored education. However, we would like to report these results because they were surprising and may be of interest. Additionally, they emphasize the need for students to learn how to critically appraise literature.

The initial database of RCT assessments contained 506 assessments of which 49 assessments were considered deviant and these were therefore removed from the database. Thirty-five new assessments were added because a reference was assessed less than three times. The final database consisted of 492 assessments concerning 144 individual references, which appeared in 59 separate advertisements. Sixty-nine appeared in Huisarts en Wetenschap only, 44 appeared in Modern Medicine only, and 31 appeared in both journals (Figure 1). The mean reference validity score for references appearing in Huisarts en Wetenschap only (n=69) was 13.34 and of those appearing in Modern Medicine only (n=44) 14.36 (Table 1). Using our cut-off point of validity score 16, approximately 80% of references appearing in Huisarts en Wetenschap only were considered being of suboptimal quality, in contrast to approximately 70% of the references appearing in Modern Medicine only. The references appearing in advertisements in Modern Medicine scored on average 1.03 (95% CI, 0.41 to 2.02) points higher than those appearing in Huisarts en Wetenschap. References related to Modern Medicine scored higher regarding blinding of the study (questions five, six, and seven), on average 0.29 (95% CI, -0.01 to 0.59) points higher on blinding of the patient, 0.25 (95% CI, -0.03 to 0.53) points higher on blinding of the care provider, and 0.26 (95% CI, 0.04 to 0.48) points higher on blinding of the outcome assessor.

Total

Huisarts en Wetenschap

alone

Modern Medicine

Alone Both

Drug category N Score N Score N Score N Score

Cardiovascular 45 14.36 14 14.82 13 14.89 18 13.62

Pulmonary 24 13.90 7 14.82 13 13.98 4 12.00

Diabetic 27 12.14 22 12.06 5 12.50 - -

Other 48 14.10 26 13.21 13 14.94 9 15.43

Total 144 13.78 69 13.34 44 14.36 31 13.93


Figure 1: Flow chart of the assessment process.

The 59 advertisements contained information on 44 different drugs. For all drug categories, the mean reference validity score is shown in Table 2. The mean reference validity scores for cardiovascular, pulmonary, and diabetic drug categories were 14.36, 13.90 and 12.14 points, respectively. Hence, the mean reference validity score of diabetic drugs is 2.22 (95% CI, 0.96 to 3.48) points lower than the mean reference validity score of cardiovascular drugs and 1.75 (95% CI, 0.20 to 3.30) points lower than the mean reference validity score of pulmonary drugs. As noted in Table 2, the references in the diabetic drug category appeared mainly in advertisements in Huisarts en Wetenschap. This bias could explain the difference in mean reference validity score. The difference on the reference validity score between both journals, when excluding the diabetic drug category, was smaller, that is 0.63 (95% CI, -0.34 to 1.60) points.

Discussion The main aim of this study was to assess the opinion of students about research-tutored learning. The results of our study show that this type of learning is an effective way for students to develop an additional set of skills improving their futures as clinicians. This type of research tutored learning not only lets the students benefit from research, students also aid research.

Our results show students are positive about research-tutored education. We tried to achieve optimal reliability of the results from the questionnaire. This was achieved by asking 255 students to fill out the questionnaire and by analyzing the results anonymously. Even though the results only apply to the specific circumstances created during the course Scientific Education, these circumstances can easily be recreated by any medical faculty in the world in order for students to benefit from research-tutored learning. The use of self-assessment data from the students is a limitation of this study. Because we employed this method we have not directly measured if the critical appraisal skills of students actually improved. Measuring their performance relative to a “golden standard”, for instance the appraisal of a faculty member, before and after our intervention, would have given us a learning outcome to report. With our methods we cannot confirm the learning outcomes of our intervention. Despite these limitations, we believe that the reported increase of students’ self-efficacy is still relevant. We hypothesize that students with increased self-efficacy will more likely read references associated with advertisements or with new pharmacological therapies in general, because they feel that they have the skills to critically appraise these references. It is far more likely that students learn the required skills while engaging in the activity, as compared to a student with low self-

Total number of references N=144

Planned assessments N=576

Good quality assessments N=457

Total number of assessments N=492

35 additional assessments were made

10% of assessments were considered deviant

Completed assessments N=506

88% of assignments were completed

Each reference was planned to be assessed four times

Number of unique references


efficacy, who will not engage in the critical appraisal of references. Additionally, the data from the research performed by the students indicates suboptimal quality of a large portion of references; this might motivate students to critically appraise the literature they encounter during their future careers. Students were not positive about all aspects of research-tutored learning. They had difficulties relating the appraisal of RCTs and associated education to their future career. Students did, however, understand the importance of scientific training for their future as clinicians. The students’ opinion could be explained by the small part each individual student had in the research project. Possibly more effort should be made to show participating students the goal of the project, and to show them more of the data analysis part of the study. Additionally, putting more emphasis on their own development and the relevance of this type of education to their scientific development, of which students do see the importance, could improve the students’ ability to relate research-tutored education to their future as clinicians. In this study, 255 medical students assessed the quality of pharmaceutical advertisements and found that 70-80% of pharmaceutical advertisements in both journals can be considered suboptimal. The students found that the references in advertisements in the commercial journal Modern Medicine are not less reliable compared to the references in the advertisements of the independent journal Huisarts en Wetenschap. In relation to the quality of advertisements, the publication of advertisements in Modern Medicine is, like most journals, determined by the publisher which does not check the references of advertisements [Knuistingh Neven A. 2011, Former chief-editor of Modern Medicine, written communication]. Although Huisarts en Wetenschap does check if an advertisement is contradictory to the guidelines of the Dutch College of General Practitioners, the references of the advertisements are not checked either [Van Weert HC. 2011, Chief-editor of Huisarts en Wetenschap, written communication]. The lack of checking references by both journals may explain the suboptimal quality of a large part of the references and the absence of a difference in reference validity.

Selection of only a single journal from each group is a significant limitation to this study. If one or both journals are not representative to the group, results will be biased. Therefore, we cannot generalize our conclusion and we cannot make a statement about the relationship between the nature of the journal and the quality of the references in general. Using students for the assessments enabled us to examine a large number of references. However, one could argue that students might be unmotivated. In our opinion we prevented this bias with the manual containing exact guidelines on how to score every question, a one-hour informing seminar, two hour training, and an oral presentation of the content of both assigned references to their fellow students and a supervisor. Students validated the clearness of the assessment criteria for the RCTs as 3.93 (SD 0.84), which means assessment criteria were clear. In addition, four students assessed each reference independent from each other and blinded from the origin of their reference. The precise instructions in the manual ensured they would score the references similarly, as is illustrated by the fact that only 49 out of 506 assessments were considered deviant. Panel discussions with two groups of eight and four students confirmed that students took this assignment seriously. Since the quality of RCTs appearing as references in advertisements has not been well-studied, additional research is needed to improve the knowledge in this field. Furthermore, the possibility of selection of those references with an outcome favorable to the drug advertised would have to be taken into account when regarding the quality of advertisements. We studied the difference between a commercial and scientific journal concerning the reliability of the references in their advertisements. Although more research is needed to clarify the relationship between the nature of the journal and the quality of the references in its advertisements, this study’s conclusion is unexpected but in line with previous research.19 References in advertisements from a commercial journal are not less reliable, compared to references in advertisements from an independent journal. Several factors might attribute to this: the suboptimal quality of the references in general, the journals lack of focus on advertising policy, or the lack of criticism from readers regarding their advertising policy.


Conclusion The opinion of students regarding this type of research-tutored learning was positive and they rated the course meaningful for their future as clinicians. They experienced an improvement of their presentation skills and the feedback at the presentation was rated valuable. In addition, they stated to have improved their critical appraisal skills and understand the importance of reading literature during their career. Concluding, this type of research-tutored learning is being rated an effective way for students to develop an additional set of skills improving their future functioning as clinicians. The course design, combining research and education, not only lets the students benefit from research, they also aid it. Secondary to the results above, we found that in both the commercial and the independent medical journal, 70-80% of included references scored suboptimal. After adjustment for drug category, the quality of references from a commercial journal, are not less reliable, compared to those of an independent journal.

Acknowledgements The authors would like to thank all students who contributed to this study.

Keywords Research-tutored learning, students, randomized controlled trial, learning gain, critical appraisal.

Notes on Contributors VINCENT T. JANMAAT is a medical and biomedical sciences student, Leiden University Medical Center, Leiden, The Netherlands. KIM E. KORTEKAAS is a medical student, Leiden University Medical Center, Leiden, The Netherlands. THOMAS M. MOERLAND is a medical student, Leiden University Medical Center, Leiden, The Netherlands. MAYKE W.C. VEREIJKEN is an educational consultant, Center for Innovation in Medical Education, Leiden University Medical Center, Leiden, The Netherlands. JAN W. SCHOONES is collection management coordinator and information specialist, Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands. ASTRID VAN HYLCKAMA VLIEG, PhD is a postdoctoral researcher, Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands. FRIEDO W. DEKKER, PhD, is Professor at the department of Clinical Epidemiology, and former head of the Center for Innovation in Medical Education, Leiden University Medical Center, Leiden, The Netherlands.


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Appendix




ORIGINAL RESEARCH

An e-Learning Intervention to Enhance Medical Student’s Competence in

Oxygen Delivery Methods

Shana Godfred-Cato, Michael Metts, Greg Kolbinger,

Edward P. Finnerty & Kyla Carney Des Moines University, Des Moines, IA, USA

Abstract Purpose: Student performance in a comprehensive clinical simulation exercise at the end of the 3rd year had demonstrated some deficiencies in oxygen delivery methods. A tutorial exercise was developed to remedy this issue. This study assessed if an e-learning intervention improved the student’s competence in oxygen delivery methods during the comprehensive clinical simulation lab. Methods: An independent study tutorial describing proper oxygen delivery methods was developed and made available to all 3rd year students through our course management system. The tutorial program consisted of a pre-test, video illustrating the proper use of oxygen delivery equipment and a post-test. The pre-test was required to be completed before the video was made available and the post-test was only available after the video was viewed. The post-test and the course evaluation included questions regarding student satisfaction. Video recording of the group simulation exercises were made of the classes before the tutorial was introduced and after for comparison. Results: Of the 217 students in the course, 136 (63%) completed the pre-test and 119 of those completed the post-test. There was a significant improvement in performance on the post-test compared to the pre-test (87% ± 14 vs. 61% ± 13; paired t-test, p < 0.001). There was an overwhelming perception of value with 92% responding favorably that the program increased their knowledge of oxygen delivery methods. A large majority (88%) were satisfied with the ease of use of the tutorial video. Evaluation of the video records did not reveal any appreciable differences, though a number of the recordings were not useable and could not be assessed with our scoring rubric. Conclusions: The results of the study demonstrate that students who utilized the tutorial program improved their knowledge of oxygen delivery methods. A limitation of this study is that we were unable to ascertain if the knowledge translated into an improved performance in the simulation exercise. This study does show that an independent e-learning module can enhance medical students’ education.

Introduction The Institute of Medicine report, To Err is Human, reported that between 44,000-98,000 patients die each year from medical errors. Medical errors cost between $17-$29 billion dollars per year in hospitals all across the United States.1 For these reasons there is a huge movement in medicine to identify causes of medical errors and to find ways to prevent medical errors in the future. Improving medical education may be one way to reduce medical errors in the hospital and clinics.

The practice of medicine is often referred to as both a science and an art. Within this context, the healthcare provider must be competent in both a large body of knowledge as well as a range of skills involving a variety of procedures in addition to a number of other qualities (AOA Competencies, ACGME Competencies). The ultimate goal for the learner is to transfer this knowledge and skill set to the practice of medicine. The use of Simulation technology holds a valuable place in the medical education curriculum as it provides a safe and controlled practical application of the knowledge and skills.2,3

Corresponding author: Edward P. Finnerty, PhD, Department of Physiology/Pharmacology, Des Moines University 3200 Grand Avenue, Des Moines, IA 50312; Tel:+1 515-271-1649; Fax: +1 515-271-7149; email: [email protected]


While the use of simulation manikins and other high tech strategies promotes engagement and learning, some of the simpler measures can also serve as valuable tools to promote learning and retention. While reading textbooks and other resources are useful means of learning, simply re-reading material is not an effective tool.4 Ample evidence in the medical education literature supports using a variety of e-learning modalities to help students in the medical fields.5-7 With the variety of instructional strategies available, it is sometimes hard to determine which is more effective. Video instructional guides have been used for many years, but the digital age has made their use much easier and more versatile; Zull argues that presenting students with several learning modalities allows student knowledge to be more complete.8 Ghude advocates the value of a video in combination with a simulation exercise as it incorporates the four learning styles: visual, auditory, reading/writing and kinesthetic.9 Cendan and Johnson, in their study of the use of an e-

learning module in combination with a manikin-based simulation exercise for the management of shock, report that the combination is effective and that using the e-learning module prior to the simulation improved learning.10 O’Leary and Janson, using a combination of an e-learning module with pediatric CPR instruction found significant improvement in performance and cognitive abilities.11 Simply using an e-learning module alone can be an effective and efficient teaching strategy.7 One value of using an e-learning modality is that it can be accessed and used at the learner’s convenience. Mikalsen and Walderhaug surveyed a cohort of students regarding their attitudes towards e-learning. In their report the students reported that the e-learning modules fit well with the way they studied and the improved course organization ratings supported that.12 It seems that students are happy with the ability to use e-learning in place of or as a supplement to traditional learning.

Event Points

3 2 1 0

A Time to O2 administration after O2 saturation <95% (Time 1)

< 20 sec 21-40

sec 41-60 sec > 60sec

B Liters of O2 adj #1 (O2 1) 1-5 L

C Equipment (1) NC/ Facemask

Intubate Nothing D Liters adj #2 (O2 2) Flow appropriate to device

E Equipment (2) NC/ Facemask/NRB

F

Time to intubate/bag, O2 saturation not maintained at 90% c NRB mask (Time 2)

< 20 sec 21-40


G Bag or intubate (3) Bag

Intubate

H Time b/t bag to intubate (Time 3) < 20 sec 21-40


I Bag or Intubate #2 (Final) Intubate

Table 1: Simulation Exercise Scoring Rubric.

Incorporating a testing paradigm within the learning module further reinforces the learning. Using a pre- and post-test permits the student to recognize their strengths (or deficiencies) and thus makes the learning more fitted to their needs. In addition, testing itself is a useful teaching strategy. The testing effect has been found to be a strong and significant factor in learning.13,14 At Des Moines University, third year medical student’s return to campus for a capstone exercise incorporating several didactic instructional units and assessments. One of the assessments is a Simulation exercise. In 2010, a deficiency was noted regarding students use of oxygen delivery devices. To address this, we developed an e-learning module

incorporating a pre- and post-test measure. This report is a summary of our findings with this intervention.

Materials and Methods Overview This study was conducted at the Iowa Simulation Center at Des Moines University. The study was approved by Des Moines University institutional review board. The student’s participation in the e-learning modality on oxygen delivery methods was voluntary while participation in the simulation exercise is a required component of the Clinical Comprehensive Examination course for all third year medical students at Des Moines University.


Participants The third year medical students (n=217) enrolled in the required Clinical Comprehensive Examination course were the subjects of this study. e-Learning tutorial An independent study tutorial describing proper oxygen delivery methods was developed and made available to all students (COM 2012) through the Angel course management system for the Clinical Comprehensive Exam unit (July 2011). This tutorial program consisted of a pre-test assessment, a short

video illustrating proper use of the various O2 delivery equipment available in hospitals and a post-test assessment. The pre- and post-test assessments were essentially the same. Two questions were added to the Post-test assessing satisfaction with the video presentation. The tutorial program was structured such that the pre-test assessment was required to be completed before the instructional video was made available. The post-test assessment was only available after the video was viewed.

Item Pre Post

1. How much oxygen can be appropriately given with a nasal cannula? 93.5% 100%

2. How much oxygen can be appropriately given by a simple mask? 85.5% 99.2%

3. How much oxygen can be appropriately given with an aerosol mask 7.2% 70.8%

4. How much oxygen can be given appropriately given with a non-rebreather mask? 38.4% 82.5%

5. How much oxygen can be appropriately given with a venturi mask? 34.1% 86.7%

6. If you have a 55 year old male patient with a saturation that fell to 90% and the patient was complaining of shortness of breath and their respiratory rate was 22, what amount of oxygen would you use and which device?

86.2% 88.3%

7. If the same patient's saturation further fell to 85% and they had increasing shortness of breath with a respiratory rate of 26 with dizziness, what would be the appropriate next action to take?

47.8% 92.5%

8. If the same patient's saturations fell to below 80% and they were non-responsive, what would your next action be?

91.3% 97.5%

Total correct responses for each item of all students completing the pre- and post-assessment.

Table 2: Performance on Pre-and Post-test assessment.

Simulation Exercise A simulation exercise is included as part of the Clinical Comprehensive examination. The students are assigned to teams of five with each individual assigned a particular role in the team. The simulation case used involved an element of respiratory distress requiring the student teams to recognize the problem and intervene with appropriate treatments as the case develops. The simulation experience was recorded and the students were assessed on their choice of oxygen device chosen, the amount of oxygen delivered through the device at three points in the case and the length of time before choosing to intubate the patient once they showed signs of respiratory failure. Students were also evaluated on their intubation skills. Video recordings were made of the same simulated case exercise during the Clinical Comprehensive Exam unit in July 2010, the year prior to development of the study tutorial, and used for comparison.

The course evaluation included questions regarding student satisfaction with the e-learning program. Performance Rubric To assess whether the cognitive knowledge from the video could be translated to the clinical setting, a grading rubric was designed and used to evaluate team performance using the recordings of the simulation experience (Table 1). This grading rubric was developed by the research team and based on the O2 delivery practices. The rubric was used by one faculty member to evaluate all of the videos to minimize inter-grader discrepancies. Unfortunately, the videos did not always allow for an adequate determination of the events for collection of data. Despite these difficulties, using the scoring rubric, points were assigned for each of the events for each group where possible. The events were collapsed into a Time category and an Equipment category. The ‘Time’ category was defined as the scores for Time 1, Time 2 and Time 3 from the scoring rubric. ‘Equipment’ was defined as the Equipment, O2 adjustment and ‘Bag or Intubate’ scores. A percent


score was calculated for each (Time and Equipment) based upon the number of available measures and possible points. Data Analysis The pre- and the post-test scores were assessed by an item analysis and a repeated measures t-test was employed to compare the pre- with the post-assessments. An independent measures t-test was

employed to assess the Time and Equipment performance scores from the Scoring Rubric from the two cohorts (2010 and 2011). Student satisfaction as reported in the course and post-assessment surveys is reported as descriptive data.

Did you feel that the video increased your knowledge on oxygen delivery methods?

Yes No

92.5%

7.5%

How satisfied are you with the ease of using the video?

Very satisfied 58.3%

Somewhat satisfied 29.2%

Neutral 5.0%

Somewhat dissatisfied 4.2%

Very dissatisfied 3.3%

Table 3: Student Satisfaction.

Results Of the 217 students in the course, 136 (63%) completed the pre-assessment. Seventeen (17) of the 136 students did not complete the post-assessment, leaving 119 students (55%) of the medical class completing the entire e-learning module. There was a significant improvement in the post-test scores compared to the pre-test scores (87.2 ± 13.6 vs. 61.3 ± 13.4, p < 0.001). The e-learning modality appeared to be beneficial to the students that participated. Table 2 shows the performance of the students on the pre- and post-assessment tests for each item. While performance was comparable for many of the items, several demonstrated appreciable differences between the pre and post periods. Recognition of the limits of oxygen delivery by the aerosol, non-rebreather and venturi masks all showed low performance in the pre-test. After viewing the tutorial video, performance on the same items showed substantial improvement. The application item (#7) also showed improvement after viewing the video. The students were highly satisfied (87%) with the use of the video and felt that it contributed to their knowledge (92%), Table 3.

Though the performance scoring rubric was designed to evaluate individual group performance we were unable to effectively use it for all groups in the two cohorts. Using the scores as described, we did determine that there was no apparent difference in the percent scores for Time or Equipment between the two groups (2010 vs. 2011, Table 4).

Discussion The number of students that participated in the e-learning modality was acceptable, although with more students participating a clearer sense of the value of the video tutorial could be assessed. A goal might be to require the student’s use of the e-learning modality prior to the clinical comprehensive exam. The current results demonstrate an overwhelming perception that the video was a valuable experience, and easy to use. The pre- and post-test assessments allowed us to assess students’ knowledge of varying oxygen delivery devices and the amount of oxygen each device requires for proper use. The amount of oxygen required for proper use of the nasal cannula had a very high correct response rate on the pre-test most likely due to the wide use of the nasal cannula in many medical settings. This is also true of the simple face mask. Those two oxygen delivery devices are the most common ones used in


medicine; therefore, most students are exposed to them during their clinical rotations. Students performed poorly on the questions regarding the aerosol, re-breather and venturi masks and that is likely a reflection of the little, if any, exposure to these devices on rotations. The higher post-test scores suggest that the e-learning modality (video) was beneficial to medical students and should be incorporated into the curriculum as an adjunct to the traditional didactic lectures. Year

2010 2011 p

Time 30.6 ± 28% 33.2 ± 25% 0.691

Equipment 74.8 ± 24% 72.0 ± 17% 0.589

mean ± SD, see text for explanation

Table 4: Simulation Exercise Performance for Time and Equipment Skills

The scoring rubric was designed to assess the behavior of the student groups during the clinical simulation exercise. This would have allowed us to make a connection between the cognitive knowledge and its transfer to behavioral action. The video recordings were incomplete and difficult to use as an assessment tool of the group activities for a variety of reasons. Two different simulation rooms were used for the simulation exercise and in those rooms the video recordings were not always picking up the same information. Oxygen flow was not always documented by the students on the whiteboard in the simulation room or was not picked up by the video recording. Introducing measure to better control for these issues would enhance the value of the recordings, and in turn permit a better assessment of the scoring rubric. Over 87% of the students using this module responded that they were either very satisfied or somewhat satisfied with the ease of use of this as a learning tool. Lecture in medical school has been a traditional practice but as we learn more about student learning styles in a world full of technology it seems clear that our students appreciate a different style of teaching and learning. The difficulty encountered in assessing the student group performance with the scoring rubric presents a significant limitation to the study. The recordings of the simulation exercise should document the actions and provide a means to assess. Another limitation is linking the cognitive performance as assessed by an individual student in the pre- post-test measures to their behavior in the group

simulation exercise. If a greater percentage of students had participated in the e-learning modality, then we would have been more confident that their knowledge may have influenced the behavior in the simulation exercise. As it is, we cannot make that connection. Future work should look at addressing this limitation.

Conclusion From the data collected on the use of an e-learning modality it can be concluded that an e-learning modality does enhance medical student education and increase performance on a written test. More data would be required to conclude that e-learning modalities also increase medical student’s performance in clinical scenarios. Since we were able to document improved performance on the written exam it is likely that we could make this e-learning experience a required part of the comprehensive clinical exam week and with the changes suggested in the discussion obtain greater knowledge of how this intervention truly affects the clinical decision making of the student learners during their capstone simulation experience, and lead to the development of a core group of e-learning modules for our students.

Notes on Contributors SHANA GODFRED-CATO, DO, is a Pediatric Resident at McLane Children’s Hospital Scott & White, Texas A&M Health Science Center College of Medicine, Temple, TX, USA. This work was part of her Pathways of Distinction while a medical student at Des Moines University, Des Moines, IA, USA. J. MICHAEL METTS, DO, is Assistant Professor and Interim Chair of the Department of Specialty Medicine, Des Moines University, Des Moines, IA, USA. GREG KOLBUNGER, PA-C, is Assistant Professor, Department of Family Medicine, Des Moines University, Des Moines, IA, USA. KYLA CARNEY, DO, is Associate Professor, Department of Family Medicine, Des Moines University, Des Moines, IA, USA. EDWARD P. FINNERTY, PhD, is Professor, Department of Physiology/Pharmacology, Des Moines University, Des Moines, IA, USA.

Keywords Simulation, Medical education, e-learning


References 1. Kohn, LT, Corrigan, JM and Donalsons, MS.

(2000). To Err is Human: Building a Safer Health System. National Academy Press, Washington, D.C.

2. Cook, DA, Hatala, R, Brydges, R, Zendajas, B, Szostek, JH, Wang, AT, Erwin, PJ, Hamstra, SJ. (2011). Technology-Enhanced Simulation for Health Professions Education: A Systematic Review and Meta-analysis. JAMA 306: 978.

3. Cook, DA. (2009). The Failure of e-Learning Research to Inform Educational Practice and What We Can Do About It. Med Teacher 31:158.

4. Calender, AA and McDonial, MA. (2009). The Limited Benefits of Rereading educational Texs. Cont Educ Psychol 34: 30.

5. Kerfott, BP, Baker, H., Jackson, TL, Hulbert, WC, Federman, D, Oates, RD and DeWolf, WC. (2006). A Multi-Institutional Randomized Controlled Trial of Adjuvant Web-Based Teaching to Medical Students. Acad Med. 81:224.

6. Ruiz, JG, Mintzer, MJ and and Leipzig, RM. (2006). The Impact of E-Learning in Medical Education. Acad Med. 81: 207.

7. Riedstra, AW, Maarleveld, HJ, de Jong, PGM and van den Broek, PJ. (2010). Spotlighting Basic Hospital Hygeine Rules: The Implementation of E-Learning. JIAMSE 20(2s): 214.

8. Zull, J. (2002). The art of changing the brain. Sterling, VA: Stylus publishing, pp 47, 53, 84, 95, 249-252.

9. Guhde, J. (2010). Combining simulation, instructor-produced videos, and online discussions to stimulate critical thinking in nursing students. Computers, Informatics, Nursing, 28(5): 274.

10. Cendan, JC and Johnson, TR. (2011). Enhancing Learning Through Optimal Sequencing of Web-based and Manikin Simulators to Teach Shock Physiology in the Medical Curriculum. Adc Physiol Educ. 35: 402.

11. O’Leary, F, & Janson, P. (2010). Can e-learning improve medical students’ knowledge and competence in paediatric cardiopulmonary resuscitation? A prospective before and after study. Emergency Medicine Australasia, 22(4): 324.

12. Mikalsen, M., & Walderhaug, S. (2009). An investigation of factors influencing healthcare workers' use and acceptance of e-learning in post-school healthcare education. Studies in Health Technology and Informatics, 150: 893.

13. Roediger, HL and Karpicke, JD. (2006). Test Enhanced Learning: Taking Memory Tests Improves Long-term Retention. Psychol Science 17: 249.

14. Larsen, DP, Butler, AC and Roediger, HL. (2008). Test-Enhanced Learning in Medical Education. Med Educ. 42: 959.




MONOGRAPH

Teacher Training for Students and Faculty in a Medical School Environment

Michael S. Risley Albert Einstein College of Medicine, Bronx, New York, NY, USA

Abstract Teaching excellence in both the basic and clinical sciences is an expectation of students and regulatory agencies (LCME). The quality of teaching may in fact have a larger impact than curriculum structure on the quality of learning. Nevertheless, many teachers in the basic and clinical sciences have not received formal pedagogical training resulting in a broad diversity in skills and educational quality. This article describes a program at the Albert Einstein College of Medicine that integrates mentored teaching with formal pedagogical training to provide a rich training environment to enhance the teaching skills of students, fellows and faculty and meet the accreditation standards of the Liaison Committee on Medical education.

Introduction Since the seminal report of Abraham Flexner, medical education has experienced repeated cycles of analysis and debate regarding curricular content required to meet an ever evolving practice of medicine and the changing learning objectives and competencies.1 By itself, curricular content does not necessarily lead to increased learning, so changes in course structure and integration are also pursued as a means to improve student learning. The success of any educational effort is, however, highly dependent upon an alignment of curriculum structure, course and lesson design, assessment and teaching effectiveness. It may be argued that deficiencies in teaching skills and lesson planning may be more significant impediments to learning than any specific curriculum structure. Unfortunately, teaching effectiveness is also one the most difficult variables to address because most teachers in science and medicine have not been formally trained in pedagogy. A 2003 report of the National Research Council recognizes these principles and calls for enhanced teacher training in science to address significant deficiencies in science education.2 Handelsman et al. argued for dedicated institutional efforts to train teachers in the principles of scientific teaching - principles which

also apply to medical education.3 Formal training is important to help teachers develop strong fundamentals and continually adapt to rapidly evolving, disruptive technologies and new generations of students with enhanced technology literacy.4 Provision of teacher training in medical education is particularly important considering the diversity of “teachers” and teaching methods that medical students encounter during their basic science and clinical education. The teachers range from experienced faculty with varied skills to inexperienced and relatively untrained residents, postdoctoral fellows and graduate students. In May 2012, the Liaison Committee on Medical Education (LCME) highlighted the need and responsibility of medical schools to address teaching skills by codifying it in an accreditation standard known as ED24.5 This standard calls for institutional commitment to the monitoring, evaluation and training of non-faculty teachers acting as medical educators. As quoted in ED24

“the institution and/or its relevant departments provide resources (e.g., workshops, resource materials) to enhance the teaching and assessment skills of residents and other non-faculty instructors. There should be central monitoring of the level of residents’ and other instructors’ participation in activities to enhance their teaching and assessment skills”.

Corresponding author: Michael S. Risley, PhD, Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, New York 10461 ; Tel: +1 (718) 430-2389; Fax: +1 (718) 430 8996; email: [email protected]


Teaching is an art and science that is refined through a combination of classroom experience and formal training in pedagogy. Many medical schools provide faculty development workshops and/or web based resources as a means to support and enhance teaching skills and improve learning, and they usually conduct student evaluations of faculty teaching. A common weakness to these efforts is that they often lack mechanisms for formal coursework in pedagogy and they are not designed to assess and mentor educators of different skill levels to a specific performance level which can be documented. This article seeks to reinforce the perspective that every institution of advanced training in the basic and medical sciences should have formal mechanisms dedicated to teacher training and the monitoring and enhancement of teaching quality. The programs should continually assess teacher skills, provide mechanisms for correction of deficiencies that teachers would be required to access, and document that deficiencies have been corrected. Here I describe programs instituted at Albert Einstein College of Medicine (AECOM) which together provide a framework for coordinated training of current and future teachers that may be useful as a model for other medical schools. Formal Coursework As in any scientific pursuit, teaching should be evidence-based – teachers should understand the connections between data from educational research and the “do’s and don’ts” of teaching. Teachers should acquire a foundation of pedagogy that they can employ for design, structure and student guidance in diverse learning environments. One of the most common missing ingredients in institutional efforts to train teachers is dedicated coursework where students, fellows and faculty can learn and practice pedagogical fundamentals. Due to the typical time demands on students and educators such coursework should be highly focused on core knowledge and skills. To address this need at AECOM, I designed and implemented in 2009 a graduate course titled “Fundamentals of Course Design and Teaching”. This is a two credit course that meets once a week for two hours over 17 sessions and registration is open to every member of the AECOM community. The course is designed to integrate lecture and discussion sessions regarding pedagogical principles and research findings with group-based projects that provide attendees with direct experience in planning courses and lessons and implementing appropriate teaching methods to achieve learning

objectives. Learning teams (4-6 participants each) are formed at the beginning of the course and maintained throughout. Each team cooperatively completes a series of projects each of which contributes to the overall objective of designing a single course of their choosing. At the completion of all projects, a course syllabus with learning objectives, lesson plans and teaching methods is produced. There are no exams - instead all projects are presented to the class, repeatedly critiqued and revised until adequate. Students also prepare written reflections on what was learned from every class. All students receive an institutional certificate of successful completion and graduate students also receive two credits. The course objectives for Fundamentals of Course Design and Teaching are listed below:

1. Describe the traits most common to highly successful teachers and courses.

2. Identify the varied learning styles of adults as a basis for understanding themselves as teachers and their students as learners.

3. Differentiate significant (deep) from superficial learning.

4. Define cognitive hierarchies and backward design as fundamental principles for course and lesson planning.

5. Design lessons, courses and syllabi consistent with defined learning objectives, learning hierarchies and diversity in learning styles.

6. Understand the importance of active learning theory and varied instructional modalities to achieve active learning in diverse settings, including the lecture hall.

7. Identify approaches to formative and summative assessment of student learning and teaching/course effectiveness.

8. Define and communicate a personal teaching philosophy.

The overall theme of the course is to generate an appreciation for the effectiveness of student-centered, active learning approaches in education. Several major texts are used in the course along with a variety of research articles from primary literature.6-8 Session topics are listed in Table 1, and more detailed lesson outlines/plans may be obtained upon request. The topics studied enable each participant to better understand their roles as teachers and appreciate student diversity, to define the multiple forms of learning and how to align them, to establish a rational approach to course and lesson design, and the application of diverse teaching methods that contribute to long-term


learning, and to identify the major mistakes that contribute to poor teaching as well as the attributes of exceptional teaching.

Session Topics Session Format

1. Introduction; The Teaching and Learning Portfolio Discussion

2. Principles of Good Practice in Teaching and Course Design Discussion

3. The Course Syllabus as a Learning Contract Discussion

4. What is Learning? Cognitive Frameworks Discussion

5. Cognitive Frameworks/Defining Objectives Workshop Group Project

6. How Do Students Learn: Learning Styles Discussion

7. Teaching/Learning Strategies for Learning Style Diversity Group Project

8. Teaching/Learning Strategies: Lecture Discussion

9. Teaching/Learning Strategies: Active Learning Techniques Discussion

10. Teaching/Learning Strategies Workshop I Group Project

11. Teaching/Learning Strategies Workshop II Group Project

12. Teaching/Learning Strategies Workshop III Group Project

13. Course/Lesson Planning: Backward Design Discussion

14. Course/Lesson Planning Workshop I Group Project

15. Course/Lesson Planning Workshop II Group Project

16. Assessment of Learning Discussion

17. Assessment of Learning Group Project

* Workshops are for group presentations and peer critiques of course and lesson

design projects.

Table 1: Lesson Outline for Fundamentals of Course Design and Teaching

The course has been repeated three times and 73 registrants have successfully completed it. Registrants were a mix of postdocs, PhD and MD/PhD students, and faculty. Individual course sessions have also been attended by faculty interested in specific topics. Student evaluations of the course were conducted for three consecutive years. Student responses (1=outstanding, 2=very good) indicated that the course achieved the learning objectives stated above (1.67+/-.21) and that the course was a very good learning experience (1.57+/-.21). Faculty who completed the teaching

course later informed me that they changed the structure and teaching methods they used in their own teaching and their course evaluations significantly improved. Mentored Teaching While faculty receive assigned teaching roles, students and fellows in a medical student environment often lack teaching opportunities. An effective approach to improving current and future teaching is to closely mentor and guide students and fellows as they are engaged in teaching. Students


and fellows have access to teaching opportunities at Albert Einstein and neighboring universities throughout New York City to acquire “hands-on” teaching experiences. Within a medical college, teaching positions may also be available in lab-based courses such as Histology, Anatomy and Microbiology as well as other courses with small group sessions. As the course director for Medical Histology and Cell Structure courses at Albert Einstein Medical College, I decided to convert many of the lab instructor positions held by “outside” adjunct faculty into 2 year mentored teacher training positions for Einstein personnel. This decision enabled me to directly mentor trainees in many of the fundamental pedagogical principles taught in the graduate course described above. Eligible individuals can be at any level of their formal education (medical students, graduate students, postdocs, residents, or full faculty) but they must have the required competencies in histology. Each trainee is paired with an experienced PhD or MD faculty member and teaches a minimum of 55 hrs over two months of each year. Some of the trainees also attend the graduate course for more in depth discussions of pedagogical principles. This program of training has become very popular and primarily limited by the number of available positions and budget issues. Each year, 10-12 trainees are supported and financially compensated for their efforts. To date, 35

trainees have completed a minimum of 110 hrs of mentored teaching – some have actually taught more than two years. Each trainee is observed and critiqued by their faculty mentor on a daily basis to provide formative assessment and continual improvement of skills. At the end of the course, students formally evaluate and critique the skills of each trainee as well as each regular faculty member. The following skills are assessed using a Likert scale from 1 (unsatisfactory)-5 (excellent): 1) preparation/organization; 2) encouragement of student participation in discussions, 3) encouragement of student-student interactions; 4) effectiveness of responses to student questions; 5) encouragement of student-directed versus instructor-directed learning; 6) quality of oral presentations; 7) overall rating. Students also add written suggestions for improvement. I review all evaluations and comments and personally observe the teaching of trainees and faculty. Based on all assessments, I provide collegial counseling to both trainees and faculty regarding appropriate resources at AECOM for skills enhancement.

Figure 1: Alignment of Teacher Training, Assessment and Counseling


As a result of this rigorous approach, histology trainees and faculty routinely receive outstanding evaluations. The average score for overall teacher quality is 4.56+/-0.7 (5=excellent, 4=good) for 5885 instructor hours over course years 2007-2011. I strongly advocate for the expansion of teaching opportunities coupled with close mentoring as a means to train current and future teachers and gain rapid improvements in current educational quality. Integration of Training and Assessment Efforts As shown in Figure 1, the formal coursework described here serves as a core resource that can provide novices and experienced faculty with a significant foundation of pedagogical skills that will help improve current teaching programs as well as increase the numbers of trained faculty for the future. The course is sufficiently focused to allow individuals with tight schedules to efficiently obtain broad pedagogical training. Individuals with more specific needs can also feed into individual course sessions and workshops in a manner that is compatible with their academic and research schedules. Combined, the graduate course and Faculty Development workshops provide a rich and accessible set of opportunities for advanced pedagogical training that can address a broad range of needs among students, fellows and experienced educators. A key to the success of any approach to improve existing teaching efforts is the integration of teaching skills assessments with resources to address weaknesses. Usually, faculty receive some form of student assessment of their teaching, but often there is a lack of review and counseling regarding appropriate correction. What is called for here is a tight coordination between educator assessments, appropriate corrective training measures, and documentation of the effectiveness of the advanced training for faculty as well as teacher trainees in the medical school. This approach meets the LCME accreditation standard ED24.5 The overall training scheme in Figure 1, achieves this integration by placing counseling and mentoring for teachers at the center. The scheme indicates that educators and experienced, knowledgeable mentors discuss formal assessments and classroom observations and, if necessary, agree on a course of action for improvement via courses and workshops. After an educator participates in a course or workshops, their teaching and teaching assessments are examined and discussed again with the mentors. By increasing mentored teaching positions for students and fellows, we also enhance such integrated training for future faculty.

There are several mechanisms for teacher mentoring. Based on my experience as course director, the close mentoring of faculty and trainees is an effective means to achieve routinely high student evaluations of educators. Mentoring may also be provided by department chairs, faculty volunteers, faculty specifically hired and appointed to the task, or appointed faculty committees. At AECOM, an appointed faculty committee reviews medical school courses and course directors. Change in institutional culture is a key factor in the ability to successfully implement a broad-based and integrated program of assessment and skills improvement. Faculty need to be open to guidance and taking measures for skills improvements, and mentors, including course directors, need to be willing and able to provide such guidance without concerns for disrupting collegial relationships. A variety of incentives, including elevating the importance of teaching excellence in promotion guidelines, may be provided by an institution to encourage cultural change.

Key Words Teaching skills, teacher training, pedagogy, LCME

Notes on Contributor MICHAEL S. RISLEY, PhD, is Associate Professor in the Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, NY, USA.


References 1. Flexner A. Medical Education in the United

States and Canada Bulletin Number Four (The Flexner Report) New York City: The Carnegie Foundation for the Advancement of Teaching, pp. 346, OCLC 9795002, http://www. carnegiefoundation.org/publications/medical-education-united-states-and-canada-bulletin-number-four-flexner-report-0.

2. National Research Council. Bio2010: Transforming undergraduate education for future research biologists. Committee on Undergraduate Biology Education to Prepare Research Scientist for the 21st Century. Board on Life Sciences, Division on Earth and Life Studies, Washington, DC: National Academy Press, 2003.

3. Handelsman, J, Ebert-May D, Beichner R, Bruns P, Chang A, DeHaan R, Gentile S, Lauffer M, Stewardt J, Tilghman SM, Wood WR. Scientific teaching, Science. 2004; 304: 521-522.

4. Robin BR, McNeil SG, Cook DA, Agarwal KL, and Singhal GR. Preparing for the changing role of instructional technologies in medical education. Acad Med. 2011; 86 (4): 435-439.

5. Liason Committee on Medical Education. Functions and Structure of a Medical School. Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. May 2012, p 11, http://www.lcme.org /functions.pdf, accessed Oct 8, 2012.

6. Handelsman J, Miller S, and Pfund CV. Scientific Teaching. W.H. Freeman and Co., New York, 2007.

7. Fink LD. Creating Significant Learning Experiences. An Integrated Approach to Designing College Courses. Jossey-Bass, San Francisco. 2003.

8. McKeachie W and Svinicki M. McKeachie’s Teaching Tips: Strategies. Research and theory for college and university teachers. 13th ed. Wadsworth Publ., Belmont, 2010.




COMMENTARY

An Institutional Approach to Medical Curriculum Reform: Leadership, Hierarchy and Rigidity as

Impediments to Change

Karen Malone & Salinder Supri Ëphan Parks Consulting Solutions, UK

Introduction In light of the rapid expansion in scientific knowledge, changes in medical practice, and greater demands from patients and society, there have - particularly over the last 25 years - been changes to almost every aspect of the U.S. medical curriculum. These have included a shift towards active and student-centered learning methods; a move away from an almost exclusive focus on lectures; tighter integration of classroom learning and clinical training; and a greater emphasis on the teaching of professionalism, and the development of interpersonal and communication skills.1 Despite extensive curriculum reform, graduates still lack the knowledge, skills, and professionalism required for medical practice, with patients continuing to report that physicians do not listen, lack compassion, courtesy and respect, and exclude them from decision-making. Thus, a quarter-century of curriculum reform has neither improved medical education outcomes, nor the quality of patient care. A key explanation for this paradox is that medical education reformers have tended to view the issue of curriculum reform primarily in educational terms, that is, one involving only modifications to the curriculum, and have neglected to take account of institutional variables. These variables - which include legislation, regulation, licensing, governance, and leadership - are instrumental in shaping the healthcare system and, in turn, medical education and clinical practice. Given they frame the parameters by which healthcare organizations

operate, these variables determine reformers’ room to maneuver and their ability to make change, and can undermine the curriculum reform process.2 Our paper therefore reframes the hidden curriculum debate, placing it in the wider context of the institutional economics literature.3-5 In doing so, we provide a theoretical framework against which to explain why changes in medical education and clinical practice have either not been forthcoming or have been difficult to achieve. This new perspective shows that institutional variables fundamentally shape the learning environment, and that we have to make changes at the institutional level if we are to achieve real curriculum change, and transform medicine and patient care. The Scenario To illustrate how institutional variables operate to subvert medical education, we focus on a scenario involving the teaching of communication skills. Since communication accounts for a significant proportion of the time that physicians spend with their patients, and good communication is vital to effective diagnosis and treatment, these skills are essential to good medical practice.6 However, as the following example makes clear, despite the attempts of curriculum reformers, the teaching of communication skills continues to be a challenge. Our scenario is drawn from an observation of a clinical rotation in a U.S. teaching hospital, during which a female patient diagnosed with lung cancer asked if she would die. The attending physician simply replied "yes." Upon hearing the news, the patient burst into tears. No member of the medical team - which included doctors, nurses and students - said anything, or interacted with the patient in any other way, and all promptly left the bedside.

Corresponding author: Karen Malone, MA, Director of Education, Ëphan Parks Consulting Solutions, UK. Tel: +44 1482 213268; email: [email protected]


Uncovering the Institutional Dynamics of Medical Education Reflecting on the encounter, a third-year medical student reported that whilst she had wanted to sit beside the patient, comfort her with a hug, and reassure her that it was “okay to cry,” she had not done so. This is despite the fact that the student’s actions would have accorded with current best practice guidelines on communication issued by the Association of American Medical Colleges (AAMC), and the American Medical Association (AMA). According to the AAMC, physicians should express care, concern, and empathy to patients; facilitate emotional ventilation by giving them the opportunity to talk; and enable the exchange of information on treatment options and palliative care.7 Similarly, the AMA’s Code of Ethics specifies that “[t]he patient has the right to courtesy, respect, dignity, responsiveness, and timely attention to his or her needs.”8 Thus, the actions of the medical team ran counter to curriculum and clinical practice guidelines on communication, showing that, regardless of copious documentation and guidance on good communication practice, what happens on the ground often runs counter to what professional medical bodies seek. In fact, our student’s experience reflects the norm in clinical practice. Indeed, a recent study found that physicians failed to respond empathically to 90 per cent of the fears, worries and concerns of lung cancer patients, providing them little emotional support, despite their need for reassurance and comfort.9 We argue that this disconnect between intentions and outcomes arises due to the role of powerful, but hitherto unappreciated, institutional variables that mediate medical education and clinical practice. These institutional variables act to thwart the intentions of reformers in relation to communication skills in particular, and curriculum reform in general. Upon dissecting our scenario, two key institutional variables emerged. Leadership as an Institutional Variable When questioned as to why she had not responded empathically to the patient’s distress, the medical student reported that she had been waiting for signs from the attending physician that would permit her to convey concern, and reassure the patient. Since none were forthcoming, she felt that she had little option but to take his lead, and mirror his behavior.

The actions of leaders send out strong signals that can convey that the lessons learned in the classroom are not necessarily relevant in real world medical practice. This reflects the considerable authority that leaders within the hospital environment possess, and shows that their behavior represents the ultimate marker as to what is acceptable. So, our student realized that it was more important to emulate the actions of the head of the medical team, than to adhere to what was taught in the classroom about the importance of responding empathically to patients. Our scenario demonstrates how leaders ultimately mold the responses, and behaviors of those they lead. When leaders only pay lip-service to, or even flout, guidelines on good clinical and educational practice, their actions sanction and perpetuate inappropriate behaviors and practices. Our scenario therefore highlights the power of the institutional variable of “leadership” in helping explain why curriculum change is so often unsuccessful. If reformers are to make any real or substantive advances in transforming medicine so that it meets the demands of patients and society, we need to appreciate the important role that leaders play in medical education and healthcare reform. Hierarchy as an Institutional Variable Upon further questioning, our student revealed that whilst looking to the attending physician, she had also sought cues from the other members of the medical team to give her the green light to act. However, since they in turn took their lead from the attending physician, they too maintained a stony exterior. The team’s demeanor reinforced to her that she should show no reaction. The student then disclosed that her actions were conditioned by her awareness of her junior position within the medical team, and that due to her student status, it was more important for her to respect the hospital hierarchy than respond to the patient’s needs. The hospital hierarchy is characterized by strictly defined positions and roles, and is entrenched and absolute. It cannot be easily questioned or confronted, and imposes severe consequences on those who transgress its strictly ordered system. As a result, for those lower in the hierarchy, it is more important to observe the “pecking order,” and not “break ranks,” than to adhere to good communication practice. Our scenario therefore brings into focus the institutional variable of “hierarchy,” and its power to limit curriculum reform. Whilst essential to the practice of medicine, hierarchy has the power to


distort what students learn, and the behaviors they adopt. Ultimately, strong and deep-seated hierarchies limit curriculum reform by preserving the status quo. Leadership and Hierarchy as Sources of Institutional Rigidity The institutional variables of leadership and hierarchy combine to create a state that we term “institutional rigidity,” that is, an organizational environment in which existing systems and practices remain deep-seated and incontestable. In the case of the institutional variable of leadership, those in power often have a vested interest in preserving their position and maintaining the status quo, and so do not always embrace new curriculum or clinical guidelines. At the same time, the institutional variable of hierarchy creates an operational environment in which students are not in a position to practice in line with the curriculum, and cannot easily challenge the actions of superiors. The resulting institutional rigidity acts as a brake on curriculum reform, reinforcing and perpetuating existing educational and clinical practices. In such an organizational environment, reforms to the curriculum prove challenging to achieve, or difficult to embed.

Conclusion The scenario we have described and analyzed forces us to recognize the real world complexity of curriculum change. In particular, it shows the prime importance of the institutional variables of leadership and hierarchy, and more generally, of the wider institutional environment in which education is forged and delivered. This new perspective on medical curriculum reform aligns with the findings of several eminent economists, including Ronald Coase (1991), Douglass North (1993), Oliver Williamson (2009), and Elinor Ostrom (2009), whose Nobel Prize winning work attests to the need for an institutional perspective when approaching the issue of organizational change. Thus far however, curriculum reform has been considered to be a relatively simple, straightforward process, whereby provided that all the documentation and clearly articulated competencies are in place, the desired changes to medical education will occur. It is this “blinkered” approach that helps to explain why, despite countless efforts by reformers, there have been few real improvements in medical education, and we have been trapped in a cycle of reform without change. Only when we understand and appreciate the importance of institutional variables, will attempts

at curriculum reform produce the fundamental improvements in medical education needed to transform medicine and patient care.

Notes on the Contributors KAREN MALONE, MA (Distinction) is Director of Education, Ëphan Parks Consulting Solutions, UK, specializing in healthcare and medical education reform. Previously, Karen Malone was Professor and Director of Education at the University of Medicine and Dentistry of New Jersey. SALINDER SUPRI, Ph.D is Chief Economist, Ëphan Parks Consulting Solutions, UK, specializing in healthcare and medical education reform. Previously, Salinder Supri was Director of Änderung Consulting, New York.

Keywords Institutions, Impediments to Medical Curriculum Reform, Leadership, Healthcare Reform, Professionalism

References 1. Anderson MB. A Snapshot of Medical Students'

Education at the Beginning of the 21st Century: Reports from 130 Schools. Association of American Medical Colleges, 2000.

2. Supri S, Malone K. On the Critical List: The US Institution of Medicine. Am J Med 2011; 124(3): 192-193.

3. Hafferty FW, Franks R. The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education. Acad Med 1994; 69: 861-871.

4. Hafferty FW. Beyond Curriculum Reform: Confronting Medicine's Hidden Curriculum. Acad Med 1998; 73(4): 403-407.

5. Kentli FD. Comparison of Hidden Curriculum Theories. European Journal of Educational Studies 2009; 1(2): 83-88.

6. Stewart MA. Effective Physician-Patient Communication and Health Outcomes: A Review. CMAJ 1995; 152(9): 1423-1433.

7. Report III Contemporary Issues in Medicine: Communication in Medicine - Medical School Objectives Project. Association of American Medical Colleges, 1999.

8. CEJA Report A – A-90 Fundamental Elements of the Patient-Physician Relationship. American Medical Association, 1990.

9. Morse DS, Edwardsen EA, Gordon HS. Missed Opportunities for Interval Empathy in Lung Cancer Communication. Arch Intern Med 2008; 168(17): 1853-1858.




MEETING REPORT

A Learning Community of Learning Communities 9th annual Learning Communities Institute (LCI) meeting,

San Francisco, CA, USA, November 3th, 2012.

The 9th annual Learning Communities Institute (LCI) meeting was held in conjunction with the Association of American Medical Colleges annual meeting in San Francisco, California on November 3rd, 2012. The LCI meeting was divided in two venues: a morning at Moscone Center in San Francisco, followed by an afternoon and evening in Palo Alto at Stanford University School of Medicine. Mirroring the significant growth of learning communities within medical schools the LCI meeting had its largest attendance to date; the morning session included 111 participants representing 52 schools of medicine from the United States and Canada. Sixty-five individuals continued with the group to Stanford for further collaboration, learning, and scholarship. Learning communities (LCs) in medical schools are gaining momentum across North America. Although learning communities vary greatly from school to school their framework offers a supportive learning environment for students based on longitudinal relationships between faculty and students who share “common values and beliefs and are actively engaged in learning together and from each other.”1 Many schools have implemented advising, mentoring, traditional curriculum, clinical skills teaching, and social-wellness support into an LC foundation creating a community of learners that spans generations and levels of training. The meeting was convened by the two conference hosts, Joel Gordon (U. Iowa-Carver) and Amy Fleming (Vanderbilt University), who welcomed the participants and reviewed the history of the growing LCI group. Rob Shochet (Johns Hopkins University), the current LCI Chair fostered the community atmosphere by giving the group time to meet new members and begin conversations. The morning Keynote address “From High School to Professional School: The Learning Community Experience” was given by Jeff Gilbert, Principal at

Hillsdale High School a learning community based school in San Mateo, California, and Rachel Lotan, Ph.D. from Stanford University School of Education. This keynote session was chaired by Lars Osterberg the local conference host (Stanford University School of Medicine). Their exploration of Hillsdale’s success in high school education through LCs, the underlying educational theory behind LCs, and the educational parallels in medical education were the main themes touched on in this keynote presentation. Gilbert highlighted the importance of institutional values and beliefs that are consistent and well articulated. He emphasized a focus on the potential of each individual student and a learning environment that is personalized, rigorous (with support), equitable (to break the patterns of predictability around success), and allows shared decision making so all in the community are heard. Dr. Lotan’s presentation helped the group explore the importance of sustained and trusting relationships. Dr. Osterberg ended by addressing the principal question… “What can LCs do for you? They can create a supportive teaching environment, with a productive community of learners, educators and caregivers engaged in a dialog about patient care and medical science.”2,3

The morning research session highlighted LC innovations from 20 institutions. Four oral presentations were selected where authors led 20 minute facilitated discussions in rotating small groups. An additional 16 abstracts were presented as posters. The morning session concluded with working collaboration in small groups focusing on ideas that piqued interest and questions for the future. Over 60 participants then traveled by bus to Stanford University in Palo Alto to continue the conference at the beautiful Li Ka Shing Center for Learning and Knowledge, Stanford’s medical education facility.


A second keynote address by Dr. Abraham Verghese introduced educators to “The Stanford Medicine 25 – A means of continuing Bedside Medicine Education.” Dr. Verghese and two of his colleagues, John Kugler, MD and Errol Ozadalga MD, gave in-depth demonstrations of clinical skills teaching from traditional physical exam skills to use of hand held ultrasound devices at the bedside. The afternoon oral presentations included four hot topics in learning communities. Dr. Ban Allos (Vanderbilt University) discussed the potential for conflict when mentors have roles in academic evaluation and medical student advising. Danica Lomeli (Stanford University) discussed innovative exploration of critical incidents using faculty guided reflections within a learning community. The evolution of Hybrid Learning Communities was reviewed by Dr. Meg Keeley and Dr. Christine Peterson (University of Virginia). And finally, the contribution of 4th year student co-facilitators of preclinical curriculum was reviewed by Dr. Sunny Smith (University of California San Diego). The second poster session featuring an additional 12 abstracts related to learning communities research and innovations followed the oral presentations. Cumulatively, abstracts from Learning Communities at 24 schools of medicine were presented. Concurrent with the poster session were rotating tours of Stanford’s Center for Immersive and Simulation Based Learning led by David Gaba, MD. Breakout sessions in collaborative research, inter-professional education, faculty development, and student issues concluded the programming. During the research session two ongoing multi-institution projects were discussed and new ideas were generated for future collaboration. The wrap-up session was led by Zac Cordner, a student at Johns Hopkins University, who facilitated discussion of lessons learned and new ideas from the student perspective. A dinner reception followed and the meeting adjourned with a tour through the Stanford Rodin Sculpture Garden. There was clearly energy and enthusiasm as participants gathered ideas and enthusiasm to return to their home learning communities. The 10th LCI annual meeting will be held next year in conjunction with the AAMC meeting in Philadelphia, PA.

Notes on Contributors Amy E. Fleming, MD is an Associate Professor, Director of Medical Student Education in the Department of Pediatrics, Master Clinical Teacher, and Gabbe College Mentor, Vanderbilt University School of Medicine, Nashville, TN, USA. Joel A. Gordon, MD is a Professor of Medicine and the Faculty Director, Lois Boulware Learning Community, in the Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, Iowa City, IA, USA.

Innovations Abstracts

ORAL PRESENTATIONS

Through the Patient’s Eyes: Medical Students’ Navigation of Healthcare Systems in Learning Communities. Makia Powers, MD, MPH, FAAP, Deborah Lyn, Ph.D., Brandi Brandon Knight, Ph.D., Carey Roth Bayer, EdD, RN, CSE, Morehouse School of Medicine Introduction: Medical school curricula contain content and experiences designed to develop the next generation of physician. A notable challenge in medical education has been to explain the complexities of the healthcare system from the patient perspective.1-4

Program Description: Learning Communities (LCs) were established in 2011 for the doctorate of medicine (MD) program at Morehouse School of Medicine. Fifty-six first year MD students were divided into four LCs, led by clinical and non-clinical faculty mentors. Mentors created the interactive session, “Patient Navigation in Healthcare,” where each LC was divided into four groups and given a clinical scenario. The rationale was to allow students to analyze and navigate several healthcare cases from the patient’s viewpoint. Each small group was assigned a scenario and a list of practitioners that the patient would likely encounter. Students were allotted a set time to analyze, identify and present the practitioners in a flow map of the patient’s experience. Program Evaluation: Faculty facilitators challenged the students with questions to promote discussion as they created the patient navigation maps and recognized the complexities faced by patients. Students evaluated the session using an online survey, comprised of Likert-type questions (1-poor;


5-outstanding). Fifty-two students (93% response rate) gave an average rating of 4.02 out of 5 potential points indicating a high level of satisfaction with the interactive experience. Discussion: Student participants were able to learn about the complex nature of the healthcare system from the patient’s perspective. They used the list of practitioners to apply the interactive exercise to real patient cases during a subsequent shadowing experience at Atlanta’s largest safety net hospital. They reported their findings in subsequent LC sessions. Lessons Learned: Medical students value interactive learning sessions as educational tools to gain knowledge on navigating complex and fragmented healthcare systems from a patient’s perspective. Longitudinal Advising in Learning Community in a School with Geographically Separate Campuses--Crossing the Divide. Kathleen Watson, MD and Lilian Repesh, PhD—University of Minnesota Medical School Introduction: The University of Minnesota Medical School has two campuses separated by 150 miles, in the Twin Cities (TC, 170 students per class) and Duluth (DU, 60 students per class). After the first two years, students combine in the TC. The Duluth campus is a track with a distinct mission to provide physicians for rural family medicine and Native American health care. The AAMC reports that 91 medical schools now have regional campuses (1). We have developed a model for student advising across geographically separate campuses, missions, and the medical school curriculum using a learning community model individualized for our unique missions, culture and curriculum (2, 3). We report the organizational model, faculty development, and early outcomes. Program description: The aims of the University of Minnesota Medical School learning community (called Faculty Advisor (FA) program) are to 1) build long term relationships among students and faculty, 2) identify students’ needs and connect them to useful resources; and 3) promote professional formation throughout medical school. Since 2010 the FA program has advised cohorts of students through years one and two separately on both campuses. In April 2012 we launched the third phase of the program to continue advising during students’ third and fourth years. Students are assigned at matriculation to a FA from their home campus and FA activities include biannual

individual meetings, group sessions, and other learning activities. Major differences in FA groups between campuses are size (24 students in TC vs. 10 students in DU); number of FA’s (7 in TC vs. 6 DU); roles (pure advising in TC, teaching in DU); and FA clinical specialty (multiple in TC, all Family Medicine in DU). The third year FA program was designed to align with program aims such that all students continue with their FA and cohort. FA dyads were formed across campuses such that the DU FA is the designated advisor and the TC FA serves a backup role. Roles and responsibilities were determined by consensus among all FAs and discussed with students. The program ensures that 1) FAs can access a central web-based secure academic tracking system for their own students and communications; 2) FA’s holds biannual individual meetings with their advisees during year three; 3) FA group sessions are held for all year three students on the TC campus focused on “significant events reflections” conducted by TC FAs in conjoined groups of TC+DU advisees; and 4) TC FA’s meet with and write MSPE Summary section for all students incorporating DU FA comments on students. Faculty develop is essential. An annual retreat using a learning community model focuses on key advising need, e.g. year three scheduling, academic enrichment, and career selection. Program evaluation is done formally annually based on the three FA program aims. Informal evaluations are done after each group session and shared with all FAs and the medical school. In our 2011 LCME Independent Student Analysis, 98.6% of students reported being satisfied with advising. Discussion and Lessons Learned: Preliminary results after 6 months show that FA dyads are sharing responsibilities for student academic advising, career development, rotation scheduling and writing MSPE Summaries. FAs and students are using central processes and shared resources for academic tracking, career planning, student educational enrichment opportunities and faculty development. There is preliminary acceptance by students and we await formal evaluations. Geographic distance remains the largest challenge. Through program development and mutually shared responsibilities, the Faculty Advisors themselves have formed trust and a learning community whose practices, culture, aspirations and outcomes have been genuinely rewarding and gratifying for all involved.


The Use of Learning Communities to Teach Medical Students Teamwork, Professionalism and the Determinants of Health in a Community Setting. Joseph Kiesler, MD, Zélia M. Corrêa, M.D., Ph.D., Anne Gunderson Ed.D, GNP University of Cincinnati College of Medicine Introduction/Aims: In 2011, the University of Cincinnati College of Medicine implemented an organ system-based curriculum, which included faculty facilitated learning communities (LC) of 12 students and longitudinal courses relating to primary care, interprofessional care and the physician’s role in society. The Physician and Society curriculum emphasizes professionalism, ethics, community and population health, the business and law of medicine and medical humanities. To teach first-year medical students about the determinants of health of a community, foster professionalism when working with colleagues and the community, and develop teamwork skills, the Physician and Society course linked each learning community with a neighborhood and community agency in Greater Cincinnati. Program Description: In the fall, each LC completed a community health assessment of their neighborhood, focusing on one determinant of health. This culminated in an adjudicated poster session, with each LC presenting. In the winter, each LC rejoined their community partner for a service-learning project, based on the needs of the community and the needs assessment. Learning communities presented the service-learning outcomes to community members, faculty and peers in the spring. Program Evaluation: At the end of each module, students completed a Team Climate Survey, reflections, and course evaluations. The initial Team Climate Survey and reflections were discussed in LC’s to facilitate development of teamwork. LC scores improved in 11/15 areas on the Team Climate Survey. Discussion: Learning community team identity increased through completion of the modules, working through the phases of team development (forming, storming, norming, performing, re-orienting). The modules allowed the course to use experiential learning to teach the determinants of health, professionalism and teamwork in a community setting utilizing the learning communities.

Lessons Learned: Challenges included coordination and communication with community partners, communication and development of team building skills within the learning community groups, and division of work within teams. Developing a Cadre of Learning Communities Mentors. Michael Ennis, MD and David Hatem, MD University of Massachusetts Medical School Introduction/Aim(s): At UMass, LC’s were established in 2010. Incoming students are randomly assigned to a House Mentor who currently follow a total of 25 students (6-7 from each class year). Mentors teach their students clinical skills and also have individual advisory meetings with their students 3 times annually (minimum). These sessions focus on personal adjustment, professional development, academic achievement, and career guidance. Our aim is to describe the faculty development program designed to support skills of our mentors. Program description: We have 20 House Mentors from internal medicine, pediatrics, family medicine, emergency medicine, OB/GYN, and psychiatry with a mean of 25 years clinical experience (range 5 - 45). Considering such diverse backgrounds we instituted a weekly program focused on the development of teaching and mentoring skills addressing topics such as teaching clinical skills, effective feedback, characteristics of effective mentoring, typical medical student development, etc. Medical student career development is a longitudinal thread. Specific topics were next covered including preparation for upcoming PD sessions as well as helping students with academic, mental health, student maltreatment, and professionalism issues. We featured sessions on the unique aspects of advising LGBT, URM, or MD/PhD students. To enhance effective networking skills, House Mentors developed extensive knowledge about services, resources, and extracurricular opportunities available at UMass. As Mentors gathered each week they evolved into their own learning community. This relationship was powerfully manifested in our 'Mentoring the Mentors' sessions, when Mentors presented (de-identified) students whom they were having challenges with and got advice from their peers. Program evaluation: Participants completed written evaluations following each session.


Discussion: Mentors from a wide range of backgrounds bring many strengths to a learning communities program, however, intensive faculty development covering a wide range of topics is required to ensure that students receive consistent services from their mentors. For example, a mentor who is a psychiatrist may be poised to recognize a student with depression but may require a more intensive refresher to teach physical diagnosis. Lessons Learned: Development of competent LC Mentors requires ongoing intensive faculty development balancing didactic content with interactive sharing of experiences. Successful implementation of a consistent LC mentoring program also requires significant faculty development on use of on-line resources.

POSTERS The “POD System”: An Innovaive Strategy to Reform GME Teaching Sessions. Scott J. Stevens, MD; Alice Fornarum ED.D, R.D.; Ronald Kanner, MD, Hofstra North Shore-LIJ School of Medicine

Second-Year Medical Student Reflections: A Pilot Study to Prevent Decline in Empathy. Jana K. Zaudke MD, MA, University of Kansas Medical Center

Medical Student Learning Communities: Developing Professionalism, Clinical Skills, and Mentoring Relationships. Gauri Agarwal, M.D., F.A.C.P. University of Miami Miller School Maintaining the “Family Atmosphere” through Learning Communities amidst an Increasing Class Size. Carey Roth Bayer, EdD, RN, CSE, Deborah Lyn, PhD, Martha Elks, MD, PhD, Morehouse School of Medicine A Tale of Two Curricula: The Merger of a Doctoring Course and a Mentoring Program. Mary E. Rocha, MD, MPH, Christina St. Michel MD, Crystal Wright, MD, Cayla Teal PhD, Elizabeth Nelson, MD, Baylor College of Medicine Analysis of student attitudes about learning community structure and efficacy. Alan E. Harzman MD, Rolling Nagel PhD, Jennifer Burgoon PhD, Joanne Lynn MD, Daniel Clinchot MD, David Way MEd, Catherine Lucey MD, Robert Ruberg MD, The Ohio State University

Functional Mentorship in one Learning Community: Inception, Growth, and Continuity. Meaghan Dehning, Serena Edwards, Gerald Wickham, Linda Birkhofer, Vincent Liu, University of Iowa Carver College. Learning Communities at a New Medical School with a Small Class: Lessons Learned after the First Year of Implementation. Julie C. Servoss, MD, MPH, Suzanne Weiner MD, Joseph Ouslander MD, Stuart Markowitz MD, Lindsey Henson MD, PhD, Florida Atlantic University Evaluating an Advisory Dean Program: A Program Evaluation Strategy. Aubrie Swan Sein, MD, Lisa Mellman MD, Boyd Richards MD, Columbia University I’m right, you’re wrong: Teaching effective conflict management among peers using Learning Communities. Aleeia Johnson MD, Brandi Knight, Carey Bayer EdD, RN, Deborah Lyn, PhD, Makia Powers MD, MPH, Morehouse School of Medicine Determining need for a structured advising program. Courtenay Holscher BSE, Terri Blevins MA, Maureen Garrity Ph.D, University of Colorado “Wards to Words” Using Learning Communities and Critical Clinical Events to Assist in Professional Development of Medical Students. Crystal C. Wright, MD; Mary Rocha, MD, Cayla Teal PhD, Linda Stellies, Christina St Michael MD, Elizabeth Nelson MD, Baylor College of Medicine Creating a Learning Community pilot, “Energize your Medical Education (EME)” program, for underrepresented, underprepared Medical School Incoming students. Christine Reichert, M.A., Patricia Metting, PhD, Patricia Hogue, PhD, Joni Trempe MEd, University of Toledo Health Science Campus Learning communities within learning communities: Benefits for students and faculty. Barbara Sheline MD, MPH, Victoria Kaprielian, MD, Duke University Using Academic Communities as a Structure for Multifaceted Approach to Discussion Challenges in the Clinical Learning Environment. Daniel Tarman, Carolyn Kelly MD, Sunny Smith MD, University California San Diego


Competitions in Medical School Learning Communities. Van T. Nguyen, Zac Cordner, Robert Shochet MD, Amy Fleming MD, Johns Hopkins University and Vanderbilt University. Innovations in Learning Community-based Clinical Skills Evaluation. Paul Gordon, MD, MPH, Kevin Moynahan, University of Arizona 'E-Harmony' in the Colleges peer mentoring system – analyzing and improving the effectiveness of Vanderbilt Medical School’s Big/Little peer mentoring program. Jana Bregman, Sarah Coggins, Mitch Odom, Amy Fleming MD, Vanderbilt University Novel Strategy to Re-Engage Third and Fourth-year Medical Students in Learning Communities: Overview and Outcomes of the “Learning Community Grand Rounds”. Joel A. Gordon, MD, Gerald Wickham MA, Paul Meirick, BA, University of Iowa Efficacy of a developmental biology learning community on promoting and strengthening interdisciplinary collaborative behaviors. Elise R. Pfaltzgraff, Richard Samade PhD, Rebecca Adams, Daniel Levic, David Bader PhD, Amy Fleming MD, Vanderbilt University The Johns Hopkins University learning environment survey (JHULES): Development and validation of an efficient tool to assess student perceptions of the medical school environment. Robert Shochet, MD, J. Colbert-Getz PhD, Scott Wright MD, Johns Hopkins University Medical Student Distress And The Impact Of A School Sponsored Wellness Initiative. F. Joseph Real MD, Matthew Zackoff MD, Mario Davidson PhD, Beth Ann Sastre MD, Vanderbilt University Reflecting through learning communities: A unique opportunity to provide instruction while maintaining student openness. E. Michael Powers, MBA, Amy Fleming MD, Quentin Eichbaum MD, PhD, MPH, Vanderbilt University Educational Outcomes Associated with a Learning Community Implementation. Jim Wagner, MD, MSc, University of Texas Southwestern Medical School

Curriculum Variation in Implementing a New Physical Diagnosis 2 Course through Learning Communities. David Hatem MD, Timothy Gibson MD, University of Massachusetts Spheres of Influence: Faculty Benefits and Costs Beyond the Learning Community. Erika Schillinger MD, Bahij Austin, Paula Adams Hillard MD, Kambria Hooper MEd, Lars Osterberg, MD, MPH, Stanford University. Mock Residency Interviews: Preparing Students for Success in the Residency Application Season. Michael A. Pilla, MD, Amy Fleming MD, Elizabeth Sastre MD, William Cutrer MD, Ban Allos MD, Scott Rodgers MD, Vanderbilt University Development Of A Comprehensive Model And Implementation Guide For Medical School Wellness Programs. Matthew W. Zackoff MD, Scott Rodgers MD, Beth Ann Sastre MD, Vanderbilt University

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Wandersman A. Sense of community through Brunswick's lens: A first look. Journal of Community Psychology 1986;14:24-40.

2. Ferguson KJ, Wolter EM, Yarbrough DB, Carline JD, Krupat E. Defining and describing medical learning communities: Results of a national survey. Acad Med 2009; 84:1549-1556.

3. Hirsh DA, Ogur B, Thibault GE, Cox M. "Continuity" as an organizing principle for clinical education reform. N Engl J Med. 2007 Feb 22; 356(8):858-66.




MEETING REPORT

Interprofessional Education in the Health Sciences

An IAMSE Webcast Audio Seminar Series

Winter series, January 12 – February 23, 2012

The strong national and international call for Interprofessional Education (IPE) in health professions programs, though not a new concept, has generated considerable interest in the past several years. IPE extends beyond simply having students from various programs attending common classes together. An IPE curriculum is designed to promote an understanding, appreciation and application of the roles, talents and responsibilities of the members of the health care team. The Winter IAMSE webcast seminar series convened a collection of the leaders and programs that have successfully implemented IPE activities. The series commenced with an overview of IPE, its expansion over the years followed by a perspective on the fundamental elements of developing a successful program. Specific sessions focused on multiple implementation approaches including: An IPE course incorporating a community-based service learning project, an IPE Honors Colloquium, clinical clerkship IPE experiences, a comprehensive curricular design and a set of IPE activities including the requisite faculty development to make it all happen.

With this in mind, an experienced and dynamic cadre of educators shared their insights and experiences and the series commenced with:

Learning Together to Practice

Collaboratively: Some Principles for

IPE In this session John Gilbert, CM, PhD, FCAHS, provided the foundational historical prespective of interprofessional education for patient centered collaborative practice. The presentation proceeded to discuss the fundamental principles that need to be acknowledged and systemized for creation of IPE on university and college campuses and across health care systems. For the presentation slides go to: http://www.iamse.org/development/2012/was_011212/011212.pdf For the Webinar recordings go to: http://iamse.org/development/2012/published_was/was_011212/was_011212.html

Strategies for Launching a

Successful IPE program In this session, Amy Blue, PhD, mentioned some of the challenges in establishing and implementing successful programs. The challenges included issues of leadership commitment, faculty and student buy-in, coordination across programs, academic calendars and class schedules, faculty development and resources. Dr. Blue proceeded to discuss successful strategies for launching a sustainable IPE program at Medical University of South Carolina (MUSC) academic health center. Unique to the MUSC IPE program is the inclusion of biomedical graduate studies students. An example program implementation framework and conceptual learning

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model with associated student learning goals were presented. Required IPE student learning experiences, extra-curricular IPE experiences, and faculty development activities were highlighted. Student assessment and program evaluation approaches were discussed. The session objectives were to: discuss strategies for IPE program implementation; describe IPE curricular activities; identify how IPE can be included in the extra-curricular environment; and identify IP student assessment and program evaluation approaches. This session informed institutions embarking on the development of IPE activities and establishment of a program with possible approaches for their own efforts. To achieve added insight into described strategies, view Dr. Blue’s presentation slides at: http://www.iamse.org/development/2012/was_011912/was_011912.pdf

Interprofessional Teams,

Culture and Service Learning

– An Interprofessional First Year Experience for Students at Rosalind

Franklin University of Medicine and

Science In this session Susan K. Tappert, PT, DPT and Diane R. Bridges, MSN, RN, CCM discussed the Interprofessional teams and culture in Health Care course at Rosalind Franklin University of Medicine and Science. The course introduces students to the concept of interprofessional teams, the influence of culture in health care, and the importance of service learning.

The speakers detailed the logistics of student enrollment in the course, described how students were divided into interprofessional teams, the utilization of small group discussion to achieve the course purpose of preparing the health care professional student to provide effective patient-centered health care through small group discussion and problem solving activities. Additionally, barriers and challenges to the creation of successful course were examined.

The presentation included description of the following topics included in the course: team interaction; communication; service learning; information literacy; quality improvement; healthcare professions,; diversity in society; the impact of culture, ethnicity and religion on communication and the provision of services;

disparities in the healthcare delivery system; and awareness of the impact of a provider's own wellness and illness beliefs on the decisions he/she makes for patients.

The speakers proceeded to describe how the interprofessional teams of students developed and participated in significant community need based service learning projects. The purpose of the service project was to promote Prevention Education in the areas of Physical Fitness, Preventive Screening, Nutrition, and Making Healthy Choices. Upon projects completion, students created a poster, participated in reflection, and celebrated their achievement with community partners and the university at large.

For the presentation slides go to: http://www.iamse.org/development/2012/was_012612/was_012612.pdf For the Webinar recording go to: http://iamse.org/development/2012/published_was/was_012612/was_012612.html

Creating an Interprofessional Learning Community: The University

of Kentucky Deans' Honors

Colloquium During this session, the speakers recognized that health profession education programs are increasingly being challenged to prepare practice-ready graduates who deliver high quality patient/community-centered care as effective members of interprofessional teams. To meet this demand, students enrolled in health science programs at the University of Kentucky participated in a semester-long interprofessional honors course designed to provide them with a forum to explore the characteristics and implications of collaborative practice around one or more cross-cutting healthcare challenges while learning more about themselves as team members. As a result of participation in this course, students learned to understand, appreciate and value interprofessional collaboration among their colleagues.

Multiple colleges participated in needs assessment and feasibility study in 2008 and subsequent course design, planning, and implementation of the interprofessional honors colloquium. Ultimately the course has become a collaborative project across eight colleges and twelve educational programs, wherein each contributes equally-valued resources.

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Faculty from the participating colleges acted as instructors, lecturers, or small group facilitators. Students were invited by their respective deans to participate.

Twenty-six students enrolled in the course initially. Three years later, course enrollment has more than doubled and there is an impressive waiting list. Despite competing demands and limited resources, faculty retention is 100% and students frequently enroll for more than one semester. Data suggests that the course experience has an impact on students' attitudes toward, respect for, and understanding of teamwork and one another's professional roles.

For the presentation slides go to http://www.iamse.org/development/2012/was_020212/was_020212.pdf For the Webinar recordings go to: http://iamse.org/development/2012/published_was/was_020212/was_020212.html

Interprofessional Education at Case

Western Reserve University: Curricular Challenges and Meaningful

Work Case Western Reserve University's Health Professions Schools implemented a series of interprofessional workshops that bring together students from the schools of dental medicine, medicine, nursing and applied social science. In this session, the speakers shared lessons learned and successes in implementing an interprofessional workshop on obesity for over 500 students in four health professions, done entirely in small groups. The sessions had interactive, learner-centered focus and students worked in one of 46 small, interprofessional groups, each facilitated by a faculty member from one of the four health professions schools. The speakers focused on the following elements: 1) central support and clear goals, 2) a small, cohesive interprofessional planning group, 3) a small group workshop format with activities around relationship building, a common patient experience, review of each health profession's literature, and reflection, 5) evaluation, and 6) lessons learned.

This four-part series is one component of a much larger interprofessional initiative that incorporated classroom, community, and patient care settings. The overall goals for the interprofessional

workshops were to bring students together in the small group setting to: 1) interact with peers from other health professions schools; 2) describe the roles/education for each other's health professions 3) examine select articles from each profession's literature, and 4) appreciate opportunities for collaboration among our professions to improve outcomes for patients/clients/communities.

The speakers proceeded to describe the impact of evaluation data on addressing the following questions: 1) What do students perceive as salient features of each other's professions; how do student react to the perceptions of their professions by students from other health professions? 2) What is the nature of the insights that emerge about a topic when learning in an interprofessional group? 3) What opportunities for collaboration do students identify for helping people with obesity? 4) What value do students from four health professions find in interacting together?

For the presentation slides go to: http://www.iamse.org/development/2012/was_020912/was_020912.pdf For the Webinar recordings go to: http://www.iamse.org/development/2012/published_was/was_020912/was_020912.html

Interprofessional Training at Hull York Medical School In this session, Patricia McGettigan, MBBS, described her four years experience at Hull York Medical School, where she established and managed the Interprofessional Training Ward based on the 18-bed Specialist Rehabilitation Unit at Goole and District Hospital. All final year medical students participated in a two-week interprofessional training placement wherein they worked side by side with the trained staff in the Unit to provide all aspects of patient care, gaining insights into other professionals role, and sharing their own skills. Dr. McGettigan’s presentation focused on the experiences and outcomes of hands-on interprofessional training.

For the presentation slides go to http://www.iamse.org/development/2012/was_021612/was_021612.pdf







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Herding Cats: Development and

Implementation of a Multi-phase

Interprofessional Education Program In this session, Drs. Mackintosh and Tegzes described the development and implementation of the three phase interprofessional education curriculum at Western University of Health Sciences (WesternU). Included in the presentation was a brief description of the planning process, development of the curriculum and development of the assessment plan. The presenters described the development and implementation of the faculty development process that was utilized at WesternU. Additionally, the speakers shared the lessons learned throughout the process, and described the changes made to the processes and the curriculum based upon lessons learned. The presenters also provided sage advice for the participants to help them prepare for implementation of an interprofessional education curriculum/program at their respective institutions.

For the presentation slides go to http://www.iamse.org/development/2012/was_022312/was_022312.pdf

Notes on Contributors/Presenters NEHAD EL-SAWI, PhD Alabama College of Osteopathic Medicine, Dothan, AL, USA. Dr. El-Sawi is the Chair of IAMSE Webcast Audio Seminar Committee and served as Director and Moderator for the series that broadcast in the winter of 2012. JOHN H.V. GILBERT, CM, PhD, FACHS, University of British Columbia, Vancouver, British Columbia, Canada. AMY V. BLUE, PhD, Medical University of South Carolina (MUSC), Charleston, SC, USA. SUSAN K. TAPPERT, Rosalind Franklin University of Medicine and Science, Chicago, IL, USA. DIANE R. BRIDGES, MSN, RN, CCMMSN, RN, CCM, Rosalind Franklin University of Medicine and Science, Chicago, IL, USA. ANDREA PFEIFLE, EdD, PT, University of Kentucky, Lexington, KY, USA. JAMES C. NORTON, PhD, University of Kentucky, Lexington, KY, USA. PATRICIA BURKHART, PhD, RN, University of Kentucky, Lexington, KY, USA. JAMES BALLARD, MS Ed, University of Kentucky, Lexington, KY, USA. KEVIN PINTO, MS, University of Kentucky, Lexington, KY, USA. TERRY WOLPAW, MD, MHPE, Case Western Reserve University, Cleveland, OH, USA. PATRICIA W. UNDERWOOD, PhD, RN, FAAN, Case Western Reserve University, Cleveland, OH, USA. KRISTIN Z. VICTOROFF, DDS, PhD, Case Western Reserve University, Cleveland, OH, USA. SHARON E. MILLIGAN, PhD, MSW, MPH, MS, LISW-S, Case Western Reserve University, Cleveland, OH, USA . PATRICIA MCGETTIGAN, MBBS, Barts and the London School of Medicine and Dentistry, London, United Kingdom. SUSAN MACKINTOSH, DO, MPH, Western University of Health Sciences, Pomona, CA, USA. JOHN TEGZES, MA, VMD, DABVT, University of Health Sciences, Pomona, CA, USA.

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MEETING REPORT

Promises and Challenges of Virtual Learning Environment

An IAMSE Webcast Audio Seminar Series

Spring series, March 6 – April 10, 2012

Educational technology is advancing exponentially at a rapid pace and transforming the delivery of medical education. Most educators, who are faced with competing priorities and responsibilities, cannot dedicate the appropriate amount of time necessary to conduct in depth reviews of the fast developing technologies and best practices. Fortunately, an experienced and dynamic cadre of educators who have done the "deep dive" on a specific "hot topic" shared their insights and experiences at the IAMSE Spring webcast series. The series convened a group of educators who have implemented complex learning and assessment tools and reviewed the state of the art in learning management systems (LMS), mobile digital initiatives, and online assessment and related questions. The series commenced with:

Strategies for Selecting a Learning

Management System: An Experience

at the University of California Los

Angeles (UCLA) David Geffen School of Medicine Sarah Kim, PhD and Katherine Wigan, BS, MBA stated that a learning management system is a critical infrastructure for delivering a curriculum and its associated learning activities to trainees, such as discussion forums to support problem-based learning, interactive teaching materials, online testing, and e-portfolios. The current learning management system market is extremely fluid with a series of merges among commercial systems, increasing market shares of mainstream open-source systems, and untested market strengths of emerging open-source systems.

This session was organized to share recent experiences at UCLA David Geffen School of Medicine in reviewing eight learning management systems. The session covered the topics of: (1) Needs assessment involving medical students, faculty, staff and peer medical schools; (2) Developing and obtaining a buy-in from the medical school leadership on a strategic plan that specified the goal of the review process, timeline, and decision-making steps; (3) Recruiting Advisory Committee members; (4) Identifying priority learning management features and functions that are critical to the school's educational mission; (5) Arranging demos of commercial, open source and a hybrid solution of commercial/open-source approaches; (6) Recommendation of top 3 systems to the leadership and follow-up actions

Additionally, the speakers discussed and shared the multiple tools developed during the review process including the five-year cost analyses involved in adopting and implementing the top three learning management systems. Lastly, the speakers shared selected best examples from peer institutions as a way to suggest the future direction and roles of learning management systems in medical education. For the presentation slides go to: http://www.iamse.org/development/2012/was_030612/was_030612.pdf For the Webinar recordings go to: http://www.iamse.org/development/2012/published_was/was_030612/was_030612.html






Digital Strategies for your Mobile

Curriculum: Lessons Learned from

Uuniversity of California Irvine’s

iMedEd Initiative In this session, Warren Wiechmann, MD, MBA, provided an in-depth description of one of the first iPad-based medical school curriculum. Specifically, the discussion focused on digital content and textbooks - platforms available, featured comparisons, and decision-making process for acquisition - as well as applications used as supplements to the curriculum. For the presentation slides go to: http://www.iamse.org/development/2012/was_031312/was_031312.pdf For the Webinar recordings go to: http://www.iamse.org/development/2012/published_was/was_031312/was_031312.html

Web Objective Structured Clinical

Examination (OSCE): an online tool

to remotely encounter standardized

patients for the practice, assessment, and remediation of

clinical skills In this session Dennis Novack, MD and Christof Daetwyler, MD described how novel WebOSCE technology allows learners to remotely encounter real Standardized Patients (SPs) - using web cam equipped computers. During a WebOSCE Encounter, the learners first are provided with the case presentation - for example the learner meets with Ms. Dundee who wants to quit smoking - then the learner performs a smoking cessation counseling session. The SPs are trained to assess the performance using a standardized checklist. At the end of the encounter, the learners are provided with individual, constructive, high-quality feedback on each item on the scoring list. Additionally, learners are provided with an individualized list containing learning assignments to address deficits.

WebOSCE has been developed for medical students, international graduates, and out-of-training physicians who seek re-entry into the work force to assess and enhance their clinical skills competencies. The speakers mentioned that the modality is particularly beneficial for participants those who live in remote areas, or have busy schedules that do not permit easily travel. The speakers advised participants to visit http://webcampus.drexelmed.edu/webosce for

literature references and a video documentation on how WebOSCE works. For the presentation slides go to: http://www.iamse.org/development/2012/was_032012/was_032012.pdf For the Webinar recordings go to: http://www.iamse.org/development/2012/published_was/was_032012/was_032012.html

Copyright and Fair Use in Terms of

Social Media Peter G. Anderson, DVM, PhD mentioned that “sharing” is the one dominant concept that best describes utilization of social media. Sharing on social media is inclusive of thoughts, photos, and prose. Dr. Anderson proceeded to note that all shared posts are instantly globally distributed and cached permanently on unlimited servers. As social medial utilization in educational endeavors increases, issues arise regarding copyrights, fair use, and other legal issues that are often viewed as annoyances by some academics. In this session, Dr. Anderson discussed issues of copyright and fair Use in the context of Social Media. He outlined some of the basic dos and don'ts and provided context and compass to teaching faculty. For the presentation slides go to: http://www.iamse.org/development/2012/was_040312/was_040312.pdf For the Webinar recordings go to: http://www.iamse.org/development/2012/published_was/was_040312/was_040312.html

Online Exams: Opportunities and

Challenges In this session, Edward C. Klatt, MD, mentioned that the delivery of examinations for students online is now possible around the clock worldwide. Dr. Klatt added that, providing examinations online is inclusive of both formative examinations for practice with self-assessment; and summative high-stakes examinations for a grade. In this presentation, Dr. Klatt reviewed multiple aspects of online exam development and usage. He addressed the questions of: what educational resources can be made available for student self-assessment in a non-secure mode, and do they improve student outcomes? what are the institutional issues regarding development, deployment, and usage of















online practice exams? Other questions addressed in the presentation related to high-stakes examinations taken in a secure mode and what methods of delivery are available? how are the examination item banks developed? What kinds of questions can be placed onto these exams? what are the challenges for timely and reliable delivery of secure online exams? what are the hardware requirements? how are scores, statistical analyses, and results produced? what are the institutional personnel requirements? And, problems encountered in delivery of these examinations. Overall, session discussed the institutional and student advantages for adoption of online exams. For the presentation slides go to: http://www.iamse.org/development/2012/was_041012/was_041012.pdf For the Webinar recordings go to: http://www.iamse.org/development/2012/published_was/was_041012/was_041012.html

Notes on Contributors/Presenters NEHAD EL-SAWI, PhD, Alabama College of Osteopathic Medicine, Dothan, AL, USA. Dr. El-Sawi is the Chair of IAMSE Webcast Audio Seminar Committee and served as Director and Moderator for the series that broadcast in the spring of 2012. SARAH KIM, PhD, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA. KATHERINE WIGAN, BS, MBA, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA. WARREN WIECHMANN, MD, MBA, University of California Irvine School of Medicine, Irvine, CA, USA. DENNIS NOVACK, MD, Drexel University College of Medicine, Philadelphia, PA, USA. CHRISTOF DAETWYLER, MD, Drexel University College of Medicine, Philadelphia, PA, USA. PETER G. ANDERSON, DVM, PhD, University of Alabama, Birmingham, AL, USA. EDWARD C. KLATT, MD, Mercer University School of Medicine, Savannah, GA, USA.









Announcements

IAMSE 2013 meeting The next annual meeting of the International Association of Medical Science Educators (IAMSE) will take place in St Andrews, Scotland (UK). The meeting theme is: “Science education for health care professionals across the continuum”. The meeting is designed for all those who teach and lead curricula in the sciences of medicine and health. Participants include basic scientists and clinical faculty from many health care disciplines. The IAMSE meeting offers opportunities for faculty development and networking across the continuum of health care education. Conference dates are June 8-11, 2013. For more information: www.iamseconference.org

Association of Clinical Anatomists The 30th annual meeting of the AACA will be held in Denver, Colorado at the Marriott City Center Hotel - July 9th - 13th, 2013. On July 9th, the Scientific Program will start and run through Friday, July 12th. The post-graduate course is scheduled for Saturday, July 13th. This year the course will be held out at the new University of Coloarado Medical Center site in Aurora. We will be sectioning a structure during the meeting and the dataset will be ready for hands-on use by attendees on Saturday. See: http://www.clinical-anatomy.org/

Medsation 2013 Oklahoma State University Center for Health Sciences is holding its 3rd Annual Medsation Conference in Tulsa, Oklahoma July 31 or August 1, 2013. That is correct July 31 OR August 1. This is a one day conference. However, the entire program is being repeated a second day to allow clinical staff the opportunity to keep clinics running and release only a portion of their staff each day. So you can pick either July 31 or August 1 to attend. For additional conference details, visit our website at http://centernet.okstate.edu/oed/medsation.cfm . Registration is now open. Cost is $125 and the deadline is July 29, 2013.

AMEE Conference The theme of AMEE 2013 is “Colouring outside the lines”. The conference will be held in Prague, Czech Republic , from 24-28 August 2013. 2013 is an historic year in the life of AMEE, and represents forty years of AMEE conferences. Teaching, learning and assessment will of course form the basis of the AMEE 2013 programme as it did at the first conference, but the range of additional topics and sessions is truly amazing. The theme of this year’s Conference is Colouring Outside the Lines, where the organization challenges presenters to cast away preconceived ideas and think whether there are new ways of working to produce future healthcare professionals to meet the needs of society in these times of limited resources. www.amee.org.

Webcast Audio Seminar 2013

Fall series The topic of the Fall WAS series will be: “Times are Changing: Evolution and Revolution in Medical Education 2013 Edition”. The series of 6 lectures will start September 12, 2013. For more details and dates, see www.iamse.org.

Individual Journal Subscriptions

Available Medical Science Educator is accessible for IAMSE members. If you are not a member, you can obtain an individual subscription. Visit this link to apply: www.medicalscienceeducator.org/subscription.html

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2013 IAMSE ANNUAL MEETING

St. Andrews, Scotland (UK) June 8-11, 2013

Science education for health care professionals across the continuum

Registration is open! Registration fees starting at $ 1,090 including accommodations & meals!

Several pre-conference workshops and sessions. Special Saturday program on Technology in Health Science Education.

Tours available for exploring Scotland.

For more information visit http://www.iamseconference.org/ and http://www.amee.org

Registration open!

Supported by AMEE



The Journal of the International Association of Medical Science Educators JOB POSTING

The American University of the Caribbean School of Medicine (AUC) St. Maarten, Netherlands Antilles

Associate Dean of Medical Education and Faculty Development

Since 1978, American University of the Caribbean School of Medicine (AUC) has provided students with quality medical education and has more than 4,500 graduates who are licensed and practicing medicine throughout the world. AUC is committed to providing a high-quality, internationally recognized program of medical education and is accredited by the Accreditation Commission on Colleges of Medicine (ACCM). AUC students are eligible to sit for the USMLE, obtain U.S. Federal Financial Aid if qualified, become active members of the American Medical Student Association (AMSA) and, upon graduation, obtain residency and licensure throughout the United States. AUC’s curriculum is the U.S. medical school model, with two years of medical sciences taught at the St. Maarten campus, followed by two years of clinical sciences taught at affiliated hospitals in the United States and England. The University is known for its student–centered environment, a faculty passionate about teaching, and a commitment to giving students who have the desire, the persistence, and the intellectual capacity an opportunity to become outstanding physicians. 96% of students passed USMLE Step 1 on their first attempt in 2012. The University seeks an innovative leader in medical education with broad intellectual capacity and collaborative leadership style together with assertiveness, flexibility, creativity, integrity, transparency, and humor. We seek candidates who have skilled academic leadership background with demonstrated commitment to success in working with diverse communities and the capacity to develop and enhance student support, retention, and student evaluation. Requirements include MD and/or Ph.D. in Medical Education or a closely related discipline with previous experience as a Department Chair and/or as an Assistant or Associate Dean of Medical Education in an accredited Medical School with expertise in curriculum development and curriculum mapping, assessment, and policy development to enhance academic integrity and quality. The successful candidate will possess the skills for guiding faculty to promote an environment that fosters not only student in-depth understanding of Basic Sciences concepts, but also integrating and bridging discipline based knowledge with practical application in Clinical Sciences. The candidate should be capable of leading the faculty to drive students to become critical thinkers and independent learners. To apply, please email your CV and letter of intent to [email protected]. We are proud to be an EEO employer M/F/D/V. We maintain a drug-free workplace and perform pre employment substance abuse testing. Thank you for applying for this outstanding opportunity today.




Instructions for Authors

Mission of the Journal Medical Science Educator is the peer reviewed publication of the International Association of Medical Science Educators (IAMSE). The Journal offers all who teach in healthcare the most current information to succeed in their task by publishing scholarly activities, opinions, and resources in medical science education. Published articles focus on teaching the sciences fundamental to modern medicine and health, and include basic science education, clinical teaching, and the use of modern education technologies.

Manuscript criteria Medical Science Educator considers all manuscripts on the strict condition that they are the property (copyright) of the submitting author(s), have been submitted only to Medical Science Educator, that they have not been published already, nor are they under consideration for publication, nor in press elsewhere. Medical Science Educator considers all manuscripts at the Editors' discretion; the Editors' decision is final. Medical Science Educator invites the following types of submissions: Short Communication, Original Research, Innovation, Opinion, Commentary, Monograph, Medical Education Case Report, Letter to the Editor, Review and Meeting Report. All parts of the manuscript must be available in an electronic format; those recommended are: generic rich text format (RTF) or Microsoft Word for text, and JPEG for graphics. Papers not correctly formatted will be returned to the authors for correction and resubmission. Manuscripts should be submitted through the website. The manuscript should be double-spaced with a wide margin (at least 3 cm) on either side. All pages should be numbered. Do not use abbreviations. All scientific units should be expressed in SI units. Before submission please remove fields from automatic referencing programs and switch off change tracking. Please supply a word count. Where figures, tables or illustrations from other publications have been used, appropriate permissions should be obtained prior to submission. Referencing should be set out in double spacing in the Vancouver style. References are to be listed numerically by order of appearance in the text, and should be indicated by the superscripted number of the reference immediately following punctuation. Please see the Journals website www.medicalscienceeducator.org for a sample article for your convenience. Manuscripts should be prepared in accordance with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (see http://www.icmje.org/) and the Committee on Publication Ethics (COPE) Code of

Conduct (see http://publicationethics.org/). Authors are responsible for all statements made in their work. When authors report experiments that involve human subjects, an indication of institutional Internal Review Board (IRB) approval or exemption should be indicated, either in the text of the manuscript or directly to the Editor-in-Chief. When informed consent has been obtained it should be included in the paper. If informed consent has not been obtained then the anonymity of the subject must be maintained.

Editorial and peer review process All submitted manuscripts are read initially by the Editor-in-Chief. One or more Associate Editors may also be involved in early decision making. Papers with insufficient priority for publication are rejected at this stage – sometimes with advice about resubmission in a different category. Other manuscripts are sent to experts in the field for peer review. The review process is usually single-blinded so that reviewers’ identities are not disclosed. We aim to give an initial decision within 10 weeks.

Proofs All accepted manuscripts are edited according to the Journal’s style. Proofs for approval will be sent to the corresponding author via e-mail as an Acrobat PDF file. Authors are required to provide corrections promptly within 4 days; if you are going to be out of email contact for an extended period, please supply us with the contact details of someone who can attend to the proofs in your absence.

Copyright Regulations For accepted papers copyright will be transferred to the journal Medical Science Educator and IAMSE. To maintain and protect the Author's and Association's ownership and rights and to afford educators with the opportunity to publish in Medical Science Educator, IAMSE requires that the first author assigns a copyright agreement to IAMSE on behalf of all the authors at the time of submission of a manuscript. In this copyright transfer agreement, IAMSE grants to the author and all co-authors, the rights to republish any part of their article in secondary publications (print, CD-ROM, and other electronic formats) for which they are authors, on the condition that credit is noted for the original Medical Science Educator publication. This copyright also extends to cover all artwork, photographs, and any other intellectual property published in the journal.

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Documents

MEDICAL SCIENCE EDUCATOR.pdf