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Dianne Wagner (College of Human Medicine Michigan State University, Internal Medicine/Dean's Office, 965 East Fee Road, A102, East Lansing, Michigan 48824, United States)
Margaret Thompson (College of Human Medicine Michigan State University, Family Medicine/Dean's Office, East Lansing, Michigan, United States)
Background: Medical educators use objective structured clinical evaluations (OSCEs) for assessment. OSCE stations can test integrated skills otherwise difficult to evaluate. Aggregating OSCE data to enable analysis of learner, clerkship and curricular outcomes is limited by station design and case specificity challenges. Strengthening the conclusions possible from OSCE data is desirable in view of their cost.
Summary of work: We blueprinted a set of formative 6-station OSCEs for 5 core clerkships. Each OSCE tests cultural and procedural competencies, use of evidence,
team behaviors, receptivity to feedback and personal learning planning. Each station enables students to practice under direct supervision and receive immediate feedback.
Summary of results: Participant evaluations are positive; obtaining immediate feedback after each station and team-challenge scenarios have been very highly rated. Blueprint-driven data is aggregated across competency and clerkship to elucidate clerkship strengths and weaknesses with respect to cultural competency, procedural skills, use of evidence in patient care, team skills, and receptivity to feedback. Conclusions: Our blueprint guided the design of a coherent set of clerkship assessments which provide a large data set on important student, clerkship, and clinical curriculum outcomes. Blueprinting simplified this challenging process. Developing clerkship OSCE stations based on a blueprint of desired competencies has enabled the aggregation of performance data and minimized case specificity challenges. Administration, faculty and students have reacted positively to the process and the product of this effort. Take-home messages: Blueprinting a set of clerkship assessments can provide helpful structure and better data on important outcomes for institutional use.
3G Short Communications: Curriculum: Hidden/Electives
Location: Conference Hall, PCC
Uncovering the Hidden Curriculum: Qualitative Analysis of Trainee and Staff Perceptions of Medical Training
Hilary Writer (University of Ottawa, Paediatrics, 401
Smyth Road, Ottawa K1H 8L1, Canada)
Asif Doja (University of Ottawa, Paediatrics, Ottawa,
M Dylan Bould (University of Ottawa, Anesthesiology, Ottawa, Canada)
Stephanie Sutherland (University of Ottawa, Academy for Innovation in Medical Education, Ottawa, Canada) Chantalle Clarkin (Children's Hospital of Eastern Ontario, Research Institute, Ottawa, Canada) Kaylee Eady (Children's Hospital of Eastern Ontario, Research Institute, Ottawa, Canada)
Background: The hidden curriculum refers to learning in response to unarticulated processes and constraints which fall outside the formal medical education curriculum. Although this has been identified across Canadian medical schools as an item requiring attention, it remains largely unknown to teachers and learners. This pilot study sought to assess the current state of knowledge and perceptions of the hidden curriculum among University of Ottawa learners and faculty. Summary of work: Focus group interviews were held with undergraduate and postgraduate learners and faculty to explore themes. Qualitative analysis was conducted using a grounded theory approach. Summary of results: Participants reflected on their own teaching and learning experiences and highlighted several key interconnected themes related to the presence of the hidden curriculum in medical training and clinical practice. These included the following: a) the privileging of some specialties over others; b) the reinforcement of hierarchies within medicine; and c) the propagation of a culture of tolerance towards unprofessional behaviours. Participants also acknowledged the importance of role modeling in the development of professional identities and discussed the deterioration in idealism that occurs during transitional stages in medicine. Conclusions: Key themes regarding hidden curricular learning emerge and overlap between teachers and learners. Further study is required to explore hidden learning in a multidisciplinary team environment as well as solutions to minimize negative learning experiences. Take-home messages: Educators must be aware that learning occurs outside the formal curriculum which significantly shapes physician professional behaviour. Strategies need to be developed to effect optimal learning outcomes from these experiences.
ABSTRACT BOOK: SESSION 3 MONDAY 26 AUGUST: 1045-1230
Keep it in Hiding: studying the hidden curriculum and lessons learned about research that challenges institutions
Susan Phillips (Queen's University, Family Medicine, 220 Bagot St, Kingston K7L 5E9, Canada)
Background: Prompted by a Canadian report on medical education suggesting that the curriculum as delivered often denigrates family physicians and certain groups of patients I surveyed a random sample of students at 3 Canadian medical schools.
Summary of work: Students wrote about teachers who marginalized individuals and groups, and their reactions to this. An unexpected barrier to doing this research involved receiving ethics approval to question students about their education.
Summary of results: Using qualitative methods, I identified the following themes from student narratives: discrimination, the insertion of preceptors' values into teaching, stereotyping by group affiliation, disrespect for colleagues and women in some specialties. No data reporting for individual schools was allowed. Students' responses to comments that startled them ranged from confusion, to self-doubt, dissociation, and transformation of personal values to fit those of the profession. Schools responded with silence. Conclusions: Despite an avowed adult education model we take a parental approach to our students. Our scientific teaching is laced with values, some of which contradict institutional ideals. Recognizing that medical science cannot be separated from the beliefs of teachers and practitioners we might consider acknowledging and discussing these beliefs rather than pretending they don't exist.
Take-home messages: The hidden curriculum, delivered by individual teachers, is unmasked for students when values conveyed clash with their own. Learners then grapple with transforming themselves so that they "fit in" to the profession. Institutional interest seems to lie in turning a "blind eye" to the hidden curriculum.
Transitioning to a 'Social Practice' Mastery Mindset in Professional Development
Kathryn Hibbert (Schulich School of Medicine & Dentistry, Western University, Centre for Education Research and Innovation, 1030, 1137 Western Rd., London N6G 1G7, Canada)
Background: There is growing appreciation of the need to prepare physicians for diversified institutional and community settings. The approach to education required to meet this diversity, demands pedagogies that assume complexity and mastery as their starting point. Literacy educators have worked through a similar experience.
Summary of work: 'Autonomous models' of literacy, founded on the premise that literacy is the acquisition and use of a set of technical skills, have historically
dominated educational practice. Problems are understood in 'deficit' terms, leading to increased training and assessment of skills as solutions. In contrast, 'ideological models' focus on social contexts; solutions attend to how practices are embedded within the broader social milieu and bound to other structures and institutions. A narrative method of 'scenario building' was used to explore pedagogical discussions in medical education around problem-based learning, evidence-based medicine, communication skills and 'point-of-care' informatics. Summary of results: A comparative analysis of theoretical tensions in all four scenarios revealed that an ideological discourse exists surrounding desired goals, but is in tension with accountability systems that privilege autonomous approaches. The literature suggests that the ideological potential of the approaches reviewed are inhibited by solutions produce from an autonomous mindset.
Conclusions: In the areas reviewed, professional development, institutional and assessment practices have not kept pace with the educational contexts they aim to create.
Take-home messages: In order to transition to a social practice 'mastery' mindset, a theoretical shift is required to create the socio-cultural and institutional conditions in which ideological models of practice can flourish, and physicians can be better prepared to meet the demands they face.
When to say 'no' - challenges facing students asked to work outside of their comfort, qualification level and/or expertise on Elective Placement
Connie Wiskin (University of Birmingham, Primary Care Clinical Sciences, and SSC, College of Medical and Dental Sciences, Birmingham B15 2TT, United Kingdom) Jonathan Dowell (University of Dundee, General Practice, Dundee, United Kingdom)
Cathy Hale (University of Birmingham, Medical Ethics and Law (MESH), Birmingham, United Kingdom)
Background: Our remit to protect patients is obvious. For students learning/working away from 'home' safeguarding processes are (often) unclear. A concern is equipping students for exposure to - and response to -uncomfortable/unfamiliar requests, where their comfort/safety, or that of the patient, may be compromised, eg when a student is asked to do something not be permitted in their own environment. This requires legal/ethical/moral reasoning. Additionally, students face the challenge of communicating response. Summary of work: Questionnaire data-collection to capture student experiences of working outside normally accepted parameters. Questions went beyond known adverse events (needlestick injury/illness/crime) to probe what students were asked to participate in. Summary of results: Sample - 228 students from Birmingham and Dundee. 2013 will include a second cohort. 50% reported being asked to do something "not
ABSTRACT BOOK: SESSION 3 MONDAY 26 AUGUST: 1045-1230
permissible" in their home institution. 25% were asked to do something they felt "uncomfortable" with, often an invasive clinical task. Half of those asked to do something not permissible in the UK were "comfortable". 45% felt it more acceptable to bypass guidelines in a developing country. 91% felt more likely to be asked to work outside their capabilities in developing world. Examples will be presented, plus student-generated definition of 'ethical' electives. Conclusions: Of interest are the reasons given for "going along with" uncomfortable invitations. Discussion includes strategies for preparing students for decision-making in new cultural contexts. Are 'home' processes are too inflexible to prepare students for 'real' medical life?
Take-home messages: Ethical decision-making and communicating reservation should be included in elective preparation. Attitudes towards developing world medicine are raised.
Australian medical student reflections on placements in Indigenous health: "I felt like I was in a completely different country."
Karen Garlan (University of Sydney, Sydney Medical School, Edward Ford Building, A27, Sydney 2005, Australia)
Lilon Bandler (University of Sydney, Sydney Medical School, Sydney, Australia)
Background: Improving the health of indigenous people is a critical and complex problem. Australian Indigenous people suffer from poorer health outcomes compared to non-Indigenous people. Addressing these iniquitous health outcomes is a challenge to the Australian healthcare system, and an important part of the medical school curriculum.
Summary of work: Using a five-step Framework analysis we analysed four years (2009 - 2013) of reflective reports from graduate entry medical students who had spent some portion of their elective term in areas with a high proportion of Indigenous patients, or in an Aboriginal Medical Service. Each researcher read the reports independently to establish an open coding scheme and identify recurring and dominant themes. Summary of results: Despite curriculum reform and continued efforts to improve students' understanding of the health issues faced by Indigenous Australians, the dominant themes exposed students' stereotyping and prejudices. Many demonstrated a 'cul-de-sac of self-congratulation' when engaging in the reflective process, instead of recognising the need for more empathic action.
Conclusions: Elective term placements may do little to help students understand the long-term crisis in Aboriginal and Torres Strait Islander health. Take-home messages: More research needs to be done to develop curricula and delivery of teaching and learning resources to aid medical students' knowledge, skills and attitudes towards Indigenous people as they attend healthcare services.
International electives in low income countries: What are students learning?
Molly Fyfe (King's College London, King's Centre for Global Health, London, United Kingdom) Paula Baraitser King's College London, King's Centre for Global Health, London, United Kingdom)
Background: Over one-third of UK medical students go on an elective in a Low or Middle Income Country (LMIC). However, the learning experience and educational outcomes from these placements are still poorly defined. We sought to understand: How students are learning while on electives in LMICs; What are students learning and, how can learning be improved during the elective placement? Summary of work: In 2012 a sample of medical students (n=9) doing electives in LMICs completed weekly electives diaries describing their on-going educational experiences. An inductive approach was taken to analyzing the diary entries (n=44). Summary of results: 'Learning Process' focused on clinical and cultural exposure and authentic practice. Less frequently students described self-directed learning or reflection. Main 'learning outcomes' were gaining awareness of different medical cultures and confidence in clinical skills. 'Missed opportunities' include lack of critical reflection and incomplete understandings, particularly concerning social determinants of health, health systems, and unfamiliar medical cultures. Students described feeling confused or conflicted but were uncomfortable discussing all issues with their local colleagues.
Conclusions: According to Kolb's Theory of Learning, students are engaging in experiential learning activities, but without adequate supported opportunities for reflection on their experiences, analysis, or synthesis of experience. Students are improving on their clinical skills and confidence, but not supported in learning in other competency domains as set out in Tomorrow's Doctor. Take-home message: Students in LMICs are engaged in clinical practice that benefits their skills and confidence. Learning from the observation of unfamiliar medical cultures and contexts could be further supported by structured opportunities for reflection that link global health concepts with students' first-hand experiences.
The benefits of a community based volunteering elective in the undergraduate curriculum
Jacqueline Daly (Royal College of Surgeons in Ireland, Biology/Anatomy, 123 St Stephen's Green, Dublin 2, Ireland)
Kenny Winser (Royal College of Surgeons in Ireland, Medical Physics, Dublin, Ireland) Celine Marmion (Royal College of Surgeons in Ireland, Pharmaceutical and Medicinal Chemistry, Dublin, Ireland)
Background: Foundation year undergraduate students (medical and physiotherapy) in the Royal College of Surgeons are given a choice of electives as part of their second semester curriculum. 21 students took part in one of these electives based on intellectual disability. Summary of work: Students volunteered once a week for 6 weeks in a community based special needs club. Members ranged from 7 to 71 years; their intellectual disabilities included Downs Syndrome, Autism, and Fragile X Syndrome. Students completed a written assignment and gave oral presentation of their experience.
Summary of results: Surveyed feedback was very positive with 100% of students agreeing they gained valuable skills related to their future careers. Qualitative feedback demonstrated an increase in student's confidence, interaction, communication, and team working skills. Students felt the elective enabled them better approach and communicate with an individual with intellectual disability.
Conclusions: This elective was positively received by foundation year students, academic staff, and the community based club. Early student experience in the community club significantly improved their interaction and communication skills. The associated assignment and oral presentation also equipped students with medical knowledge in addition to improving their team working skills.
Take-home messages: Designing and introducing a volunteering elective as part of the undergraduate curriculum is a novel way of educating healthcare professional students. It is mutually beneficial for the educational institute and the local volunteering organisation. This elective is an example of 'colouring outside the lines,' a similar design could be applied to many medically related topics linking them with volunteering organisations e.g. cancer, heart disease, and physical disabilities.
3H Short Communications: Clinical
Teaching 1 Location: Club H, PCC
Medical students' experience of learning physical examination: "Going through the motions"
Anna Vnuk (Flinders University, School of Medicine, Clinical Skills, GPO Box 2100, Adelaide 5001, Australia) Murray Drummond (Flinders University, School of Education, Adelaide, Australia)
Ben Wadham (Flinders University, School of Education, Adelaide, Australia)
Deirdre McGrath (University of Limerick, School of Medicine, Limerick, Ireland)
Background: Competency in physical examination is a core requirement in medicine. Much research has focused on the measurement of skills but little on the actual learning of physical examination. Summary of work: Using a direct phenomenological approach, medical students from years two to four (four-year medical program) were interviewed in focus groups or individually. Interviews were transcribed and analysed to develop an understanding of the lived experience of medical students as they learnt physical examination.
Summary of results: Students' experience of learning was reduced to the memorisation of the checklist and the recital of normal findings, without engagement in the actual task of physical examination or clinical reasoning. They were just "going through the motions". Conclusions: Medical students' experience of learning physical examination was deeply influenced by the impending assessment; they only learnt what was required to pass an OSCE examining SPs without "abnormal" physical examination signs. Also, they were influenced by the process, content and venue of their learning as they learnt exclusively on peers, isolated from real patients and with limited teaching or experience of the clinical reasoning process. Medical students' approach to learning physical examination focuses on the technical aspects, not on identification of signs or clinical reasoning, and this prepares them poorly for its use in real patient-care situations. Take-home messages: Constructive misalignment between educational goals, teaching and assessment will lead to unexpected learning behaviour. It is advisable, therefore, never to assume how students learn but to critically evaluate it.
Shifting Contexts and Relationships: Consequences of Transition from Longitudinal Integrated Clerkship to Rotation-Based
Jill Konkin (University of Alberta, Division of Community Engagement, 2-115 Edmonton Clinic Health Academy, Edmonton T6G 2C9, Canada)
ABSTRACT BOOK: SESSION 3 MONDAY 26 AUGUST: 1045-1230
Carol Suddards (University of Alberta, Division of Community Engagement, Edmonton, Canada)
Background: Students in UAlberta's Longitudinal Integrated Clerkship (LIC) spend their entire 3rd year in rural communities. Students return to the city for a rotation-based clerkship (RBC) for fourth year. The research question was: "What was the experience of LIC students in Year 4?" Summary of work: This hermeneutic phenomenologically guided study was conducted from 2009-2012 through semi-structured interviews with students near the end of their 4th year. Transcripts were analyzed individually and holistically for meaning, then together for emerging themes. Analysis progressed through description to grounded theory. Summary of results: Students' transition to RBC was marked by significant changes in the learning environment, in relationships with patients, preceptors and other health professionals and in students' degree of engagement in and responsibility for patient care. Most students were successful in finding meaning in the RBC experience. Many students experienced feelings of discontinuity, disengagement, confusion about their role and contribution.
The reversion from student physician (work) to student (study) described by the students affected their developing professional identities. Emphasis shifted from learning with, from and about patients to learning about patients; and from collegial and ongoing relationships to hierarchical and temporary contact. All participants experienced a sense of loss—of motivation, of agency, and of identity. Some adapted more readily than others.
Conclusions: Recognizing how the transition from LIC to RBC affects students can help develop ways to ease the transition. All clerkships need to be examined more carefully for impact on learning and professional identity formation.
Take-home messages: The structure of clerkships has significant impact on learning and professional identity formation.
Exploring medical students' learning on ward rounds
Julia Montgomery (Brighton & Sussex Medical School, Division of Medical Education, Mayfield House Rm 344a, Falmer, United Kingdom BN1 9PH, United Kingdom)
Background: Medical students attend ward rounds as part of their undergraduate training. It is known that learning in clinical settings is a complex area and there are many influences that can interact with the learning environment.
Summary of work: An ethnographic study using a case study approach was used. Obstetric ward rounds were observed by the researcher and focus groups of Year 3 medical students were undertaken to triangulate data and to develop further understanding of influences in
further depth. Analysis of the data used a thematic approach.
Summary of results: Three main themes arose from the data. Students as outsiders, learning in clinical settings and supported participation. Students felt excluded by not understanding the process of the ward round, the language used and unmet expectations. There are challenges of learning in a chaotic environment however the students valued seeing the "real" patient rather than tutorial or lecture based learning. Finally the last theme reflected the important influence that the doctor leading the ward round had in supporting students' learning.
Conclusions: There appeared to be some simple fixes that might improve learning such as signposting learning for the students. More complex areas are about developing skills that are needed by the doctor leading the ward round in order to be able to juggle the different needs of students, junior doctors, patients and other health care staff. It seems that there is a need to develop teaching skills in this complex area. Take-home messages: This is an important area of learning for both undergraduates and postgraduates. Different skills are required in order to successfully support effective learning in the clinical environment.
Narrative of the process of early clinical learning. Opinions of experienced clinical teachers
Denisse Zuhiga (Pontificia Universidad Catolica de Chile, Centro de Educacion Medica, Alameda 340, Santiago 8320000, Chile)
Marcela Bitran (Pontificia Universidad Catolica de Chile, Centro de Educacion Medica, Santiago, Chile) Isabel Leiva (Pontificia Universidad Catolica de Chile, Departamento de Enfermedades Respiratorias, Santiago,
Maribel Calderon (Pontificia Universidad Catolica de Chile, Centro de Educacion Medica, Santiago, Chile) Alemka Tomicic (Universidad del Desarrollo, Facultad de Psicologia, Santiago, Chile)
Arnoldo Riquelme (Pontificia Universidad Catolica de Chile, Centro de Educacion Medica, Santiago, Chile)
Background: The question of 'how students learn' usually leads to the study of learning styles and strategies. However, a recent investigation suggests that -during early clinical training- several additional factors are involved. Aim: To describe a narrative -built from the reports of experienced teachers- that describe the experience of medical students in the initial clinical training.
Summary of work: A qualitative methodological approach was used. Eight faculties of clinical-cycle courses were interviewed. Data was analyzed using grounded theory.
Summary of results: Four factors related to early clinical learning emerged: 'Actors', 'Activities', 'Actions' and 'Clinical Fields'. The 'Actors' category included -besides the classic triad student/teacher/patient- two additional characters: the intern (senior medical student) and the
ABSTRACT BOOK: SESSION 3 MONDAY 26 AUGUST: 1045-1230
resident. 'Activity' encompassed a myriad of educational activities organized in a theoretical and practical course, which aims at the integration of basic biomedical content through interaction with patients. The 'Actions' of students were mainly scheduled by the tutor and emphasized the critical reflection of clinical cases. Finally, 'Clinical Fields' referred to different learning scenarios: some were the formal fields articulated by the curriculum while others were self-managed by the student.
Conclusions: As can be inferred from the faculties' reports, social and situational aspects set the scene and guide the learning process of medical students at the beginning of clinical training.