Michelle Daniel

Why not wait? Eight institutions share their experiences moving United States medical licensing examination step 1 after core clinical clerkships

The majority of medical students complete the United States Medical Licensing Examination Step 1 after their foundational sciences; however, there are compelling reasons to examine this practice. This article provides the perspectives of eight MD-granting medical schools that have moved Step 1 after the core clerkships, describing their rationale, logistics of the change, outcomes, and lessons learned. The primary reasons these institutions cite for moving Step 1 after clerkships are to foster more enduring and integrated basic science learning connected to clinical care and to better prepare students for the increasingly clinical focus of Step 1. Each school provides key features of the preclerkship and clinical curricula and details concerning taking Steps 1 and 2, to allow other schools contemplating change to understand the landscape. Most schools report an increase in aggregate Step 1 scores after the change. Despite early positive outcomes, there may be unintended consequences to later scheduling of Step 1, including relatively late student reevaluations of their career choice if Step 1 scores are not competitive in the specialty area of their choice. The score increases should be interpreted with caution: These schools may not be representative with regard to mean Step 1 scores and failure rates. Other aspects of curricular transformation and rising national Step 1 scores confound the data. Although the optimal timing of Step 1 has yet to be determined, this article summarizes the perspectives of eight schools that changed Step 1 timing, filling a gap in the literature on this important topic.

A Randomized Cohort Study of Diagnostic and Therapeutic Thresholds in Medical Student Clinical Reasoning

Purpose Learning to make decisions under uncertain conditions is a critical component of diagnostic and therapeutic reasoning. This study sought to determine treatment decisions medical students make when presented with different thresholds of diagnostic uncertainty and whether they appropriately adjust diagnostic probabilities with test information. Method Two classes (2015, 2016) of fourth-year students (N = 342) were presented a patient with viral pneumonia and given 10%, 20%, or 50% pretest probabilities of that patient having a superimposed bacterial infection. Students decided to not treat, order a diagnostic test to guide management, or treat without testing based on these probabilities. The 2015 class was provided a posttest probability of 10% or 50% and asked to adjust their initial treatment decision. Results When given a low (10%) pretest probability, students were less likely to decide to treat (6%) and more likely to decide not to treat (36%). The percentage of students deciding to treat increased as the pretest probability of a superimposed infection increased from 10% to 50%, while the percentage of students not wanting to treat decreased. Interestingly, at 10%, 20%, and 50% pretest probability levels, most students were unable to decide and chose to order another test (57%, 67%, and 64%, respectively). When provided low and high posttest probabilities, students appropriately adjusted their decision making, but 29% to 32% still wanted additional testing. Conclusions Students adjusted treatment decisions to reflect different levels of diagnostic uncertainty, but varied considerably in their individual thresholds to make decisions, possibly contributing to unnecessary testing.

Teaching oral presentations in pre-clinical skills courses

research the answers and create an academic poster displaying the content material for their sub-topic. Faculty staff content experts served as resources but did not actively teach. On the final day of the SRB, all students reconvened in their original learning groups and a poster session was organised in which each student was able to sequentially present his or her work to learning group members. The students’ work was peer-evaluated using a 5-point Likert-type survey that assessed the quality of the students’ 20-minute oral poster presentations and the students’ overall effort during the research and poster preparation process. Faculty teachers used the same evaluation tool to assess the students’ performances. What lessons were learned? The poster session was tightly choreographed to allow the simultaneous delivery of multiple student presentations over an entire day. By working collaboratively, the students were actively engaged in the learning process rather than experiencing the passivity of learning through lecture. They were obliged to take an active role in researching answers and applying content material to the videotaped patient case. Every student participated in creating a poster and each student individually presented academically to peers and faculty teachers. Student evaluations of the SRB were extremely positive. Student examination scores following this review module were in line with historical comparisons. The SRB was successful in achieving its four stated goals. This educational innovation, totally devoid of lecture, promoted active learning by allowing students to individually research particular topics, work collaboratively within teams, and develop useful academic communication skills.

A cognitive apprenticeship-based faculty development intervention for emergency medicine educators

In just a few years of preparation, emergency medicine (EM) trainees must achieve expertise across the broad spectrum of skills critical to the practice of the specialty. Though education occurs in many contexts, much learning occurs on the job, caring for patients under the guidance of clinical educators. The cognitive apprenticeship framework, originally described in primary and secondary education, has been applied to workplace-based medical training. The framework includes a variety of teaching methods: scaffolding, modeling, articulation, reflection, and exploration, applied in a safe learning environment. Without understanding these methods within a theoretical framework, faculty may not apply the methods optimally. Here we describe a faculty development intervention during which participants articulate, share, and practice their own applications of cognitive-apprenticeship methods to learners in EM. We summarize themes identified by workshop participants, and provide suggestions for tailoring the application of these methods to varying levels of EM learners. The cognitive-apprenticeship framework allows for a common understanding of the methods used in clinical teaching toward independence. Clinical educators should be encouraged to reflect critically on their methods, while being offered the opportunity to share and learn from others.

Creating effective and engaging presentations

Effective presentation skills are vital tools in the clinician educator ’ s toolbox. Today ’ s learners expect more than traditional presentations that often involve speakers reading from cluttered and wordy slides. This article integrates educational theory with practical advice to provide suggestions to improve the three fundamental components of every presentation: the message, the visuals and the delivery.

Teacher Perspectives of Interdisciplinary Coteaching Relationships in a Clinical Skills Course: A Relational Coordination Theory Analysis

ABSTRACT Phenomenon: Interdisciplinary coteaching has become a popular pedagogic model in medical education, yet there is insufficient research to guide effective practices in this context. Coteaching relationships are not always effective, which has the potential to affect the student experience. The purpose of this study was to explore interdisciplinary coteaching relationships between a physician (MD) and social behavioral scientist (SBS) in an undergraduate clinical skills course. We aimed to gain an in-depth understanding of what teachers perceive as influencing the quality of relationships to begin to construct a framework for collaborative teaching in medical education. Approach: A qualitative study was conducted consisting of 12 semistructured interviews (6 MD and 6 SBS) and 2 monodisciplinary focus groups. Sampling was purposive and aimed at maximal variation from among 64 possible faculty. The data were analyzed using the constant comparative method to develop a grounded theory. Findings: Five major themes resulted from the analysis that outline a framework for interdisciplinary coteaching: respect, shared goals, shared knowledge and understanding, communication, and complementary pairings. Insights: The first 4 themes align with elements of relational coordination theory, an organizational theory of collaborative practice that describes how work roles interact. The complementary pairings extend this theory from work roles to individuals, with unique identities and personal beliefs and values about teaching. Prior studies on coteaching have not provided a clear linkage to theory. The conceptual framework helps suggest future directions for coteaching research and has practical implications for administrative practices and faculty development. These findings contribute to the sparse research in medical education on interdisciplinary coteaching relationships.

Medical student perceptions of an initial collaborative immersion experience

ABSTRACT Recent reviews of interprofessional education (IPE) highlight the need for innovative curricula focused on longitudinal clinical learning. We describe the development and early outcomes of the initial clinical experience (ICE), a longitudinal practice-based course for first-year medical students. While IPE courses focus on student-to-student interaction, ICE focuses on introducing students to interprofessional collaboration. Students attend 14 sessions at one of 18 different clinical sites. They work directly with different health professionals from among 17 possible professions, including nurses, pharmacists, social workers, and respiratory, occupational, and physical therapists. Between 2015 and 2016, 167 students completed the course, and 81 completed the end-of-course evaluation. Students agreed or strongly agreed that ICE meaningfully contributed to their understanding of healthcare teams and different professional roles (86%), improved their understanding of healthcare systems (84%), improved their ability to communicate with healthcare professionals (61%), and improved their ability to work on interprofessional teams (65%). Select themes from narrative comments suggest that clinical immersion improves understanding of professional roles, helps students understand their own future roles in healthcare teams, and increases awareness of and respect for other professionals, with the potential to change future practice. ICE may be a template for other schools wishing to expand their current educational offerings, by engaging learners in more authentic, longitudinal clinical experiences with practicing healthcare professionals.

Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review

Purpose Effective handovers (handoffs) are vital to patient safety. Medical educators investigated educational interventions to improve handovers in a 2011 systematic review. The number of publications on handover education has increased since then, so authors undertook this updated review. Method The authors considered studies involving educational interventions to improve handover amongst undergraduate or postgraduate health professionals in acute care settings. In September 2016, two authors independently conducted a standardized search of online databases and completed a data extraction and quality assessment of the articles included. They conducted a content analysis of and extracted key themes from the interventions described. Results Eighteen reports met the inclusion criteria. All but two were based in the United States. Interventions most commonly involved single-patient exercises based on simulation and role-play. Many studies mentioned multiprofessional education or practice, but interventions occurred largely in single-professional contexts. Analysis of interventions revealed three major themes: facilitating information management, reducing the potential for errors, and improving confidence. The majority of studies assessed Kirkpatrick’s outcomes of satisfaction and knowledge/skill improvement (Levels 1 and 2). The strength of conclusions was generally weak. Conclusions Despite increased interest in and publications on handover, the quality of published research remains poor. Inadequate reporting of interventions, especially as they relate to educational theory, pedagogy, curricula, and resource requirements, continues to impede replication. Weaknesses in methodologies, length of follow-up, and scope of outcomes evaluation (Kirkpatrick levels) persist. Future work to address these issues, and to consider the role of multiprofessional and multiple-patient handovers, is vital.

A Theory Based Didactic Offering Physicians a Method for Learning and Teaching Others About Human Trafficking

Emergency clinicians are on the frontlines of identifying and caring for trafficked persons. However, most emergency providers have never received training on trafficking, and studies report a significant knowledge gap involving this important topic. Workshops often employ a “train‐the‐trainer” model to address clinicians’ knowledge gaps involving various topics (including trafficking). By offering participants knowledge and skills needed to both understand relevant content and teach this content to future learners, this model aims at promoting widespread dissemination of essential information. However, current train‐the‐trainer workshops typically involve full or multiday sessions and employ multimodal instructional techniques, making them time and resource intensive for both participants and facilitators.

Experiential learning about medication adherence

Why is there a need for change? The term noncompliance implies patients should simply follow their doctor ’ s orders, rather than actively engage as participants in their own health care. The term can be stigmatising, derogatory and negatively affect the relationships that patients have with their current and future health care providers. 2 Despite this, many practising doctors persist in using the term noncompliant, fail to inquire about barriers to adherence, believe it is the patient ’ s responsibility to follow their orders and become frustrated when patients are nonadherent. 3