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Empathy among medical students: results from a Brazilian multicentric randomized study
Helena Paro (Universidade Federal de Uberlandia, Gynecology and Obstetrics, Av. Jose Zacharias Junqueira,
06, Uberlandia 38408044, Brazil)
Munique Almeida (School of Medicine of the University of Sao Paulo, Center for Development of Medical Education, Sao Paulo, Brazil)
Sylvia Enns (School of Medicine of the University of Sao Paulo, Center for Development of Medical Education, Sao Paulo, Brazil)
Renata Giaxa (Universidade de Fortaleza, Brazil) Milton Martins (School of Medicine of the University of Sao Paulo, Department of Medicine and Center for Development of Medical Education, Sao Paulo, Brazil) Patricia Tempski (School of Medicine of the University of Sao Paulo, Center for Development of Medical Education, Sao Paulo, Brazil)
Background: Empathy is an essential skill to be developed in the context of medical professionalism. We aimed to assess empathy among randomly selected
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students from 23 Brazilian medical schools and to determine its association with burnout. Summary of work: Multicentric study with 1,350 randomized medical students from all years of training. Participants answered to the Interpersonal Reactivity Index and the Maslach Burnout Inventory in an electronic survey platform. We compared empathy according to gender and year of medical school (grouped as follows: G1 - first and second years; G2 -third and fourth years; G3 - fifth and sixth years). We also correlated empathy with burnout. Summary of results: Response rate was 81.2% (n=1,350). Empathic concern (EC) and Personal Distress (PD) scores were higher among female students (p<0.01). G3 students had lower EC scores than G1 students and lower distress scores than G1 and G2 students (p<0.01). Perspective Taking (PT) scores did not differ according to year of medical training (p>0.05). PT scores were correlated to depersonalization (r=-0.3) and to personal accomplishment (r=0.3) (p<0.001). There was a correlation between: (1) PD and personal accomplishment scores (r=-0.3); (2) EC and depersonalization scores (r=-0.3) (p<0.001). Discussion: Female students had higher emotion-related empathic skills, but they also showed more distress than their male counterparts. Contrary to expected, cognitive-related skills did not differ by year of medical training. Conclusions: Female students showed higher empathic skills than males. There was an inverse correlation between empathy and burnout. Take-home messages: Medical educators should plan strategies to foster empathy and students' well being within medical curriculum.
Measure Empathy in Medical Students, differences by gender and level of medical education: An identification of a taxonomy of students
Marta Duarte (University of Beira Interior, Psychology and Education Department, Covilha, Portugal) Miguel Castelo Branco (University of Beira Interior, Faculty of Health Sciences, Avenida Infante D. Henrique, Covilha 6200-506, Portugal)
Mario Raposo (University of Beira Interior, Management and Economic Department/NECE, Covilha, Portugal) Rodrigues Paulo (University of Beira Interior, Psychology and Education Department, Covilha, Portugal)
Background: Empathy is the mediating role of the physician-patient relationship. Through this process the practitioner seeks to understand the patient's frame of reference and also to establish a relationship of openness, mutual respect, trust and deep understanding.
Summary of work: Analyze the perceptions of medical students about the importance of empathy in the doctor-patient relationship and identify a taxonomy of students based on their perceptions of empathy. A sample of 208 medical students answered to the Jefferson Scale of Physician Empathy -Student
Portuguese Version. A Principal Components Analysis with varimax rotation was used to identify the number and compositions of emerged factors. A cluster analysis identified different groups of students based on the dimensions of empathy.
Summary of results: Statistically significant differences between genders are identified. Empathy increases over the course but without statistically significant differences. Six factors emerged from factor analysis and three of them are empathy dimensions found on other studies: "perspective taking", "compassionate care" and "standing in the patient's shoes". Cluster analysis divided the students in five groups, according to the dimensions of empathy identified. Conclusions: As students progress in the course there is a greater appreciation of empathy and women when compared with men, show higher values of empathy.
10E Research Papers: Education in the
Clinical Context 2
Location: Meeting Hall V, PCC
Exploring how general surgical interns contribute to student clerkship learning
Tzu-Chieh Yu (University of Auckland, South Auckland Clinical School, Surgery, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand)
Introduction: Surgical disciplines place a distinct emphasis on apprenticeship-style teaching and training of junior colleagues and medical students. Accordingly, surgical residents and interns are recognised as important student preceptor but there is limited understanding of how they contribute to student workplace learning. A mixed-methods study was therefore conducted to explore contributions made by general surgical interns to student clerkship learning. Methods: The study involved two focus groups in June and August 2011 and the construction and distribution of a questionnaire. Focus groups consisted separately of volunteer general surgical interns and Year 4 students they had interacted with during clerkships. Utilising a qualitative analysis system, focus group transcripts were coded to generate themes. These were used to guide construction of a questionnaire distributed to a Year 4 class in September 2011. Questionnaire data were analysed using descriptive statistics, factor analysis, and Pearson correlation analysis.
Results: Focus groups were participated by six interns and five students. Intern contributions to student learning could be classified into four distinct roles: physician, supervisor, teacher, and person. Eighty-five (57%) questionnaires were returned. Interns typically interacted with students 5-6 times per week for 1-2 hours per day in surgical wards and emergency departments. Most common learning topics were interpretation of investigations (laboratory-based and radiological), bedside procedures, and administrative processes. While residents and attending surgeons were appreciated for clinical knowledge, experience, and enthusiasm for surgery, interns were appreciated for approachability, friendliness, and ability to relate to students. Interns help students integrate into the surgical team and elevated their anxiety. Achieving these tasks correlated to clerkship enjoyment (r = 0.72 -
Discussion and Conclusion: There are several reasons why intern personalities and preceptorship attitudes are significant to student learning. Firstly, after the familiar territory of preclinical learning, hospital environments are foreign and confusing making this transition a stressful time for students . Secondly, students commonly feel as if they are burdens to the surgical service . By being supportive individuals, interns impact student learning without necessarily imparting clinical knowledge and skills. When interns take an interest in students, orient them, and legitimise their
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presence, it creates a sense of belonging that enhances learning . As demonstrated, integrating students into the surgical team is one of the surgical interns' most crucial roles and can be effectively achieved by delegating clinical tasks to students. The concept is summarised by Egan & Jaye's model of Community of Clinical Practice (CoCP) . Based on Wenger's model of 'communities of practice' and learning through social interaction and legitimate participation . CoCP represents the cluster of healthcare professionals formed around the patient, united by a shared purpose of patient care. To optimise learning, students need to be integrated into the CoCP where they are exposed to actual clinical practice. The current study suggests that interns are at the centre of this process. In conclusion, surgical interns can impact student learning by demonstrating favourable interpersonal skills and attitudes. They also facilitate integration of students into the surgical team and this correlates to reduced student anxiety and improved clerkship enjoyment. These findings are important when preparing interns for clinical preceptorship.
References: (1) Paro BMS, Morales NMO, Silva CHM, et al. Health-related quality of life of medical students.
Medical Education 2010;44:227-35.
(2) De SK, Henke PK, Ailawadi G, Dimick JB, Colletti LM. Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship. Journal of the American College of Surgeons 2004;199:932-42.
(3) Hill AG, Srinivasa S, Hawken SJ, et al. Impact of a Resident-as-Teacher Workshop on Teaching Behavior of Interns and Learning Outcomes of Medical Students. Journal of Graduate Medical Education 2012;4:34-41.
(4) Jaye C, Egan T. Communities of clinial practice: Implications for health professional education. Focus on Health Professional Education: A Multidiscplinary
(5) Wenger E. Communities of practice: learning, meaning and identity. Cambridge: Cambridge University Press; 1998.
Clinical reasoning difficulties: A taxonomy for clinical teachers
Marie-Claude Audetat (Universite de Montreal, Family and Emergency Medicine, Pavillon Roger Gaudry, S-318, CP 6128 succ Centre-Ville, Montreal (Qc) H3C 3J7, Canada)
Introduction: Clinical reasoning is the cornerstone of medical practice. Most errors of clinical reasoning are not linked to gross incompetence or lack of knowledge but rather to the vulnerability of clinicians' thinking in the real world of clinical practice. Clinical reasoning difficulties have a variety of root causes which need to be differentiated if tailored remediation strategies are to be designed (1). Our study aimed to identify and describe the most common clinical reasoning difficulties as they present in residents' patient encounters, case summaries or medical notes. We also sought to develop
a Guide to support medical teachers' process of educational diagnosis and elaboration of a remediation plan.
Methods: Our research is situated in a socioconstructivist paradigm where the processes and then, the Guide, were co-constructed with clinical teachers involved at every step. We chose qualitative methodology, specifically participatory action research as defined by Kemmis and McTaggart. For these authors, participatory action research is a process of development carried out collaboratively by a group of people interested in changing practice in their setting (2). We chose family medicine residency as our setting because it is one of the specialties in which diagnostic uncertainty and the likelihood of missing or delaying diagnosis are most evident (3). We trained a group of family doctors involved in clinical education at the Department of Family Medicine and Emergency Medicine of Universite de Montreal. Eight three-hour sessions were held between April and August 2009, each representing a reflective and iterative cycle (reflection and elaboration - experimentation and observation in the clinical setting - data analysis, reflection and modification - experimentation and observation, etc), until data saturation was reached. Our findings were tested and validated on an individual and collective basis with clinical teachers from different specialties in medicine and other health disciplines. Results: We uncovered five main categories of clinical reasoning difficulties. For each difficulty we identified: indicators of these difficulties as they present in clinical supervision, examples of questions aimed at eliciting learners' clinical reasoning, explanatory hypotheses as to the root causes of the difficulty, and suggestions for remediation strategies tailored to each specific difficulty. The proposed concrete remediation strategies are based on principles of cognitive psychology and reflective practice. These findings were assembled and organized in a guide for clinical educators that will be presented to the participants. Discussion and Conclusion: We believe that the prototypical difficulties described in this Guide will help clinical teachers develop their educational scripts about clinical reasoning difficulties and facilitate their identification and the enforcement of day to day remediation strategies, even in an office setting with multiple competing demands on physician time and thinking. This research contributes to a more precise educational diagnosis of the difficulties that occur during the development of clinical reasoning. By proposing this taxonomy and educational diagnostic strategy, we hope to assist clinical educators in detecting and identifying these difficulties during clinical supervision and facilitate the provision of remediation.
References: 1. Norman G, Eva K. Diagnostic error and clinical reasoning. Medical Education 2010;44:94-100.
2. Kemmis S, Mc Taggart R. Participatory action research. in: The Sage handbook of Qualitative Research. Thousand Oaks: Sage Publications; 2005.
3. Croskerry PMDP. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic
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Rethinking clinical placements - not too much work!
Alison Ledger (University of Leeds, Leeds Institute of
Medical Education, 7.09 Worsley Building, Clarendon
Way, Leeds LS2 9NL, United Kingdom)
Shelley Fielden (University of Leeds, Leeds Institute of
Medical Education, Leeds, United Kingdom)
Sue Kilminster (University of Leeds, Leeds Institute of
Medical Education, Leeds, United Kingdom)
Introduction: To date, problems related to clinical experience and practice have been discussed in terms of the "theory-practice gap" and attributed to a lack of "preparedness" of individual students (for examples see Berridge et al., 2007; Matheson et al., 2010). Solutions have focussed on better preparation and more "high fidelity" simulation, which are dependent on conceptual frameworks which cannot fully account for the complexities of clinical practice (Kilminster et al., 2011). We are working to develop more nuanced and detailed understandings about learning in clinical settings which can inform pre-service health professionals' education and workplace practices. We are currently undertaking a series of workplace learning projects with the following research questions as a starting point: (1) How do students' participate in clinical settings? (2) How do students understand their participation in clinical settings? (3) How do other healthcare team members understand students' participation in clinical settings? Methods: This paper is based on research from two linked projects undertaken in the previous two years. The first project explored healthcare students' early clinical placement experiences and the second focussed on final year healthcare students' experiences of interprofessional work and understandings of professional roles and identities. In both projects, individual interviews were undertaken with healthcare students about their clinical placements (fifty-five students from medicine, nursing, and a range of allied health courses); the first project also included interviews with nine medicine, ten nursing, and two audiology educators. Interview responses were transcribed, read repeatedly, and interpreted using current practice-based understandings of workplace learning, which link objects, tools, texts, and bodies in webs of action (Fenwick et al., 2011).
Results: Healthcare students and educators made distinctions between aspects of clinical placements which they regarded as "learning" and aspects which they dismissed as "work". Learning was reported to occur when students were working with senior members of their own professions, when they were performing "specialised" tasks, when their participation was assessed or "signed off", or when they were taught away from patients. Students indicated that they were "working" when they worked with staff members who they perceived as low in status, when they were performing "basic care" tasks, or when an assessment opportunity was not immediately apparent. Distinctions between learning and work were most evident among
nursing students, who are expected to be "supernumerary" in clinical settings in the United Kingdom.
Discussion and Conclusion: Students' participation in clinical settings is generally understood in fragmentary ways and in accordance with individualistic assumptions about knowledge and practice. A separation of "learning" and "work" remains despite significant public concern about the quality of patient care, including the "basic care" practices identified as "work" in our study. We argue that the practices that are often dismissed as work provide valuable learning experiences in working with others, including staff, patients, and family members. All of students' participation in clinical settings should be understood as practice, which contributes to high quality patient care. Placement design and delivery should be informed by these broader conceptualisations of clinical placement learning, rather than a narrow focus on a specific set of
References: 1. Berridge, E. J., Freeth, D., Sharpe, J., & Roberts, C. M. (2007). Bridging the gap: Supporting the transition from medical student to practicing doctor - a 2 week preparation programme after graduation.
Medical Teacher, 29(2-3), 119-127.
2. Fenwick, T., Edwards, R., & Sawchuk, P. (2011). Why sociomateriality in education? In Emerging approaches to educational research: Tracing the sociomaterial (pp. 1-17). Abingdon, Oxon: Routledge.
3. Kilminster, S., Zukas, M., Quinton, N., & Roberts, T. (2011). Preparedness is not enough: Understanding transitions as critically intensive learning periods.
Medical Education, 45, 1006-1015.
4. Matheson, C. B., Matheson, D. J., Saunders, J. H., & Howarth, C. (2010). The views of doctors in their first year of medical practice on the lasting impact of a preparation for house officer course they undertook as final year medical students. BMC Medical Education, 10,
The effect of clerkship rotations on discipline-specific knowledge acquisition and retention
Wouter Kerdijk (University Medical Center Groningen, Center for Research and Innovation in Medical Education, Antonius Deusinglaan 1, FC40, Groningen 9713 AV, Netherlands)
Jos W Snoek (University Medical Center Groningen, Institute for Medical Education, Groningen, Netherlands) Roy EStewart (University Medical Center Groningen, Department of Health Sciences, Groningen, Netherlands) Arno M M Muijtjens (Maastricht University Medical Centre, Educational Development and Research, Maastricht, Netherlands)
Janke Cohen-Schotanus (University Medical Center Groningen, Center for Research and Innovation in Medical Education, Groningen, Netherlands)
Introduction: During clerkships, students learn through applying knowledge and skills and participating in practice [1,2].To facilitate student participation, longer
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rotations are recommended . Implementing longer rotations may come at the expense of the number of disciplines students rotate through. This may affect students' knowledge about disciplines they do not rotate through, which, in turn, may hamper expertise development . We investigated (1) whether rotating through clerkships affects students' discipline-specific declarative knowledge and (2) how this knowledge changes over time after the rotation. Methods: We included all 189 students who started their 3-year clinical phase at the University Medical Center Groningen in September 2007. During their clinical phase, discipline-specific knowledge was measured twelve times using progress tests. Each progress test contains a fixed number of questions per discipline. During the first two years students rotated through 14 clerkships with a duration of 4-5 weeks. The third year consisted of a scientific and a clinical elective. We included five disciplines: family practice, gynaecology, neurology, paediatrics, psychiatry. For each discipline we determined when students rotated through it. For our analyses, we used a multilevel structure with questions nested in test moments, which, in turn, are nested in students. First, we used multilevel logistic regression comparing the odds that students would answer a question about the discipline correctly before, during and after the rotation. Then we selected all questions students had filled out after their rotation and analyzed the influence of time passed since the end of the rotation on the odds that students would answer a question about the discipline correctly. In both regressions we controlled for question difficulty, gender, age and how long a student had been in the clinical phase.
Results: For each discipline, except family practice, the odds that students would answer a discipline-specific question correctly during and after the rotation were 1.33 to 2.77 times higher than before the rotation(p<0.01). For family practice the odds during a rotation did not differ significantly from the odds before it, whereas the odds after the rotation were significantly lower (odds ratio=0.84; p<0.001). After the rotation, the odds to answer a question correctly were significantly lower than during the rotation for all disciplines (odds ratio between 0.60 and 0.75; p<0.01) except paediatrics. After having finished the rotation, students' odds to answer a question correctly decreased significantly by 13% per month for neurology, paediatrics and gynaecology (p<0.01). No significant decrease over time was found for psychiatry and family practice. Discussion and Conclusion: Clerkship rotations have a positive effect on students' discipline-specific declarative knowledge. That we found no similar effect for family practice may be related to the broadness of the discipline. Discipline-specific knowledge seems to be retained, even though we found a slight decline in three out of five disciplines. Our results suggest, that facilitating students' participation in practice by means of longer clerkship rotations may lead to knowledge deficiencies in disciplines students did not rotate through. As a consequence, students' expertise development in these disciplines may be impaired .
References: (1) Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning. Medical education 2007;41(1):84-91.
(2) Holmboe E, Ginsburg S, Bernabeo E. The rotational approach to medical education: time to confront our assumptions? Medical Education 2011;45(1) :69-80.
(3) Schmidt HG, Rikers RMJP. How expertise develops in medicine: Knowledge encapsulation and illness script formation. Medical Education 2007;41(12):1133-9.
A Comparison of Three Versions of System 2 Oriented Feedback in Diagnostic Training for Ill-Defined Disease Constructs
Frank Papa (UNTHSC, Medical Education, 3500 Camp Bowie, Fort Worth 76107, United States) Kevin Kalinowski (UNTHSC, Center for Learning and Development, Fort Worth, United States)
MIchael Smith (UNTHSC, Physiology, Fort Worth, United States)
Introduction: The 'Dual-processing' (System 1/System 2) information processing paradigm has been forwarded as a means of improving instruction directed at categorization tasks such as differential diagnosis. In this paradigm, System 1 represents a pattern recognition-oriented, non-analytic/sub-conscious information processing mechanism while System 2, a feature-driven, analytic/consciously mediated mechanism. Individuals tend to preferentially utilize one information processing mechanism over the other. In recent studies involving 'well-defined diseases' (i.e., disease having necessary and sufficient diagnostic criteria), medical novices trained to utilize both System 1 and System 2 mechanisms, or a specific form of System 2 processing termed 'compare and contrast' processing, outperformed novices trained to use either System 1 or System 2 alone. However, the vast majority of human diseases are 'ill-defined' (e.g., myocardial infarction, pulmonary embolus) in that they lack necessary and/or sufficient diagnostic criteria. In this study, we sought to determine which of three different forms of System 2 contrastive training best improves the diagnostic accuracy of medical novices dealing with more commonly encountered, and difficult to diagnose, ill-defined diseases.
Methods: Following review board approval, 117 students were randomized into one of three study groups trained to diagnose each of nine common/important (albeit, clinically ill-defined) causes of Acute Chest Pain (e.g., myocardial infarction, pulmonary embolus, pneumonia). All three groups received a pre-training and post-training test consisting of the same 36 acute chest pain case vignettes (four portrayals of each of the nine diseases). Group A received compare and contrast feedback identifying features both similar across, and discriminating, the target (correct) diagnosis from their erroneous diagnosis, and, the listing of those features was in
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accordance with a traditional ordering of historical and physical (H&P) features, N=39; Group B received feedback listing only features that discriminate the target (correct) diagnosis from their erroneous diagnosis, and, the listing of those discriminating features was in accordance to a traditional ordering of H & P features, N=41; Group C received feedback listing only features that discriminate the target (correct) diagnosis and their erroneous diagnosis, and, the listing of those discriminating features was in accordance to their relative capacity to discriminate the target (correct) diagnosis from the erroneous diagnosis rather than in accordance to a traditional ordering of H & P features, N=37.
Result: The three groups did not differ in their pre-training test scores. A highly significant Cohen's D effect size improvements observed in each of the three groups (Group A = 1.29; Group B = 1.23; Group C = 1.61). ANOVA revealed that none of the three System 2 feedback formats was superior to the others (df 2; F = .098; Sig .907).