Really Good Stuff: Lessons learned through innovation in medical education

M Brownell Anderson, Muhamad Saiful Bahri Yusoff, Terese Stenfors-Hayes and Rola Ajjawi

This month’s issue contains Really Good Stuff; a collection of peer-reviewed innovations in medical education edited by M. Brownell Anderson. You can read the introduction to this section here.

‘Even now it makes me angry’: health care students’ professionalism dilemma narratives

To access on journal website, click here.

Lynn V Monrouxe, Charlotte E Rees, Ruth Endacott and Edwina Ternan

Context

Medical students encounter situations during workplace learning in which they witness or participate in something unprofessional (so-called professionalism dilemmas), sometimes having a negative emotional impact on them. Less is known about other health care students’ experiences of professionalism dilemmas and the resulting emotional impact.

Objectives

To examine dental, nursing, pharmacy and physiotherapy students’ narratives of professionalism dilemmas: the types of events they encounter (‘whats’) and the ways in which they narrate those events (‘hows’).

Methods

A qualitative cross-sectional study. Sixty-nine health care students (29 dentistry, 13 nursing, 12 pharmacy, 15 physiotherapy) participated in group/individual narrative interviews. Data were analysed using framework analysis (examining the ‘whats’), linguistic inquiry and word count software (examining the ‘hows’ by dilemma type and student group) and narrative analysis (bringing together ‘whats’ and ‘hows’).

Results

In total, 226 personal incident narratives (104 dental, 34 nursing, 39 pharmacy and 49 physiotherapy) were coded. Framework analysis identified nine themes, including ‘Theme 2: professionalism dilemmas’, comprising five sub-themes: ‘student abuse’, ‘patient safety and dignity breaches by health care professionals’, ‘patient safety and dignity breaches by students’, ‘whistleblowing and challenging’ and ‘consent’. Using Linguistic Inquiry and Word Count (liwc) software, significant differences in negative emotion talk were found across student groups and dilemma types (e.g. more anger talk when narrating patient safety and dignity breaches by health care professionals than similar breaches by students). The narrative analysis illustrates how events are constructed and the emotional implications of assigning blame (an ethical dimension) resulting in emotional residue.

Conclusion

Professionalism dilemmas experienced by health care students, including issues concerning whistleblowing and challenging, have implications for interprofessional learning. By focusing on common professionalism issues at a conceptual level, health care students can share experiences through narratives. The role-playing of idealised actions (how students wish they had acted) can facilitate synergy between personal moral values and moral action enabling students to commit and re-commit to professionalism values together.

Reflections: an inquiry into medical students’ professional identity formation

To access on journal website, click here.

Anne Wong and Karen Trollope-Kumar

Context

Professional identity formation plays a crucial role in the transition from medical student to doctor. At McMaster University, medical students maintain a portfolio of narrative reflections of their experiences, which provides for a rich source of data into their professional development. The purpose of this study was to understand the major influences on medical students’ professional identity formation.

Methods

Sixty-five medical students (46 women; 19 men) from a class of 194 consented to the study of their portfolios. In total, 604 reflections were analysed and coded using thematic narrative analysis. The codes were merged under subthemes and themes. Common or recurrent themes were identified in order to develop a descriptive framework of professional identity formation. Reflections were then analysed longitudinally within and across individual portfolios to examine the professional identity formation over time with respect to these themes.

Results

Five major themes were associated with professional identity formation in medical students: prior experiences, role models, patient encounters, curriculum (formal and hidden) and societal expectations. Our longitudinal analysis shows how these themes interact and shape pivotal moments, as well as the iterative nature of professional identity from the multiple ways in which individuals construct meaning from interactions with their environments.

Conclusions

Our study provides a window on the dynamic, discursive and constructed nature of professional identity formation. The five key themes associated with professional identity formation provide strategic opportunities to enable positive development. This study also illustrates the power of reflective writing for students and tutors in the professional identity formation process.

What’s your best time? Chronometry in the learning of medical procedures

To access on journal website, click here.

Martin V Pusic, Ryan Brydges, David Kessler, Demian Szyld, Martin Nachbar and Adina Kalet

Objectives

Most medical procedures have a time element. It is uncommon, however, to explicitly use chronometry, the measurement of time, in the learning of these procedures. This study considered whether instructional designs that include chronometry could improve deliberate practice and be used in meaningful formative assessments.

Methods

A selective review of the medical education literature was undertaken to identify how chronometry was used in a broad sampling of medical education research in the learning of medical procedures. We identified prior publications in which time measurement was used either directly as a pedagogic intervention or as an assessment method in a medical school programme.

Results

Our review suggests a number of desirable features of chronometry. For the individual learner, procedural time measurements can demonstrate both improving ability and increasing consistency. Chronometry can enhance instructional designs involving deliberate practice by facilitating overlearning (i.e. learning that goes beyond minimum competence), increasing the challenge level and enhancing self-regulation of learning (e.g. self-competition). Breaking down chronometric data into meaningful interval or split times might further inform instructional designs.

Conclusions

Chronometry has the potential to contribute to instructional designs and assessment methods in medical procedures training. However, more research is needed to elucidate its full potential and describe possible negative consequences of this widely available but underutilised educational tool.

Emotional intelligence in medical education: a critical review

To access on journal website, click here.

M Gemma Cherry, Ian Fletcher, Helen O’Sullivan and Tim Dornan

Context

Emotional intelligence (EI) is a term used to describe people’s awareness of, and ability to respond to, emotions in themselves and other people. There is increasing research evidence that doctors’ EI influences their ability to deliver safe and compassionate health care, a particularly pertinent issue in the current health care climate.

Objectives

This review set out to examine the value of EI as a theoretical platform on which to base selection for medicine, communication skills education and professionalism.

Methods

We conducted a critical review with the aim of answering questions that clinical educators wishing to increase the focus on emotions in their curriculum might ask.

Results

Although EI seems, intuitively, to be a construct that is relevant to educating safe and compassionate doctors, important questions about it remain to be answered. Research to date has not established whether EI is a trait, a learned ability or a combination of the two. Furthermore, there are methodological difficulties associated with measuring EI in a medical arena. If, as has been suggested, EI were to be used to select for medical school, there would be a real risk of including and excluding the wrong people.

Conclusions

Emotional intelligence-based education may be able to contribute to the teaching of professionalism and communication skills in medicine, but further research is needed before its wholesale adoption in any curriculum can be recommended.

Medical Education Twitter Journal Club announcement

Dear Medical Education readers,

The team supporting the journal ‘Medical Education’ will be hosting its third journal club on Twitter. The Publisher has granted free access to the selected article. The article is in the April 2014 issue of Medical Education:

The objective structured clinical examination: can physician-examiners participate from a distance?, by James Chan, Susan Humphrey-Murto, Debra M Pugh, Charles Su and Timothy Wood.

http://onlinelibrary.wiley.com/doi/10.1111/medu.12326/abstract

The authors will be ‘live’ and participating in the Twitter journal club. They have proposed some questions to stimulate some discussion, listed here:

1. Is it desirable to use DME physician-examiners in OSCEs? If so, what are barriers towards using DME physician-examiners?

2. This study suggests that remote examiner is feasible in a formative OSCE. What do you think are the limitations of remote examination?

3. Do you see any applications for remote examination other than what has been done in this study?

4. What future directions of research should be undertaken in remote examination?

You can make comments in response to the discussion questions right on the blog, or wait to make comments during the Twitter journal club.

The live Twitter journal club will be on the 1st of May, 2014 at 7PM GMT. Please note that in order to participate in the live event you must have a twitter account so please sign up now by visiting www.twitter.com. After the Twitter journal club event, the editorial staff will capture the Tweets around the discussion topics and post them to the Medical Education blog to allow those who were unable to participate in the Twitter discussion to read and comment further.

On the 1st of May at 7PM GMT, the e-Editor team (Twitter username @mededuceeditor) will be on Twitter with the article authors exchanging Tweets around the discussion questions and article. Each tweet will be tagged with ‘#mededucjc’ (for Medical Education Journal Club), so if you’d like to contribute a comment, please be sure to include that hashtag.

We are looking forward to this exciting event and hope that you are too!

Sincerely,

The e-Editor Team

The objective structured clinical examination: can physician-examiners participate from a distance?

Read on journal website here.

James Chan, Susan Humphrey-Murto, Debra M Pugh, Charles Su and Timothy Wood

Objectives

Currently, a ‘pedagogical gap’ exists in distributed medical education in that distance educators teach medical students but typically do not have the opportunity to assess them in large-scale examinations such as the objective structured clinical examination (OSCE). We developed a remote examiner OSCE (reOSCE) that was integrated into a traditional OSCE to establish whether remote examination technology may be used to bridge this gap. The purpose of this study was to explore whether remote physician-examiners can replace on-site physician-examiners in an OSCE, and to determine the feasibility of this new examination method.

Methods

Forty Year 3 medical students were randomised into six reOSCE stations that were incorporated into two tracks of a 10-station traditional OSCE. For the reOSCE stations, student performance was assessed by both a local examiner (LE) in the room and a remote examiner (RE) who viewed the OSCE encounters from a distance. The primary endpoint was the correlation of scores between LEs and REs across all reOSCE stations. The secondary endpoint was a post-OSCE survey of both REs and students.

Results

Statistically significant correlations were found between LE and RE checklist scores for history taking (r = 0.64–r = 0.80), physical examination (r = 0.41–r = 0.54), and management stations (r = 0.78). Correlations between LE and RE global ratings were more varied (r = 0.21–r = 0.77). Correlations on three of the six stations reached significance. Qualitative analysis of feedback from REs and students showed high acceptance of the reOSCE despite technological issues.

Conclusions

This preliminary study demonstrated that OSCE ratings by LEs and REs were reasonably comparable when using checklists. Remote examination may be a feasible and acceptable way of assessing students’ clinical skills, but further validity evidence will be required before it can be recommended for use in high-stakes examinations.

Task- versus ego-oriented feedback delivered as numbers or comments during intubation training

Read on journal website here.

Julian Manzone, Luc Tremblay, Kong E You-Ten, Devdatta Desai and Ryan Brydges

Context

Learners can focus on mastery (i.e. task orientation) or on learning relative to others (i.e. ego orientation). Previous research suggests task orientations are optimal for learning, a benefit usually linked to the suggestion that qualitative comments are better for learning than quantitative comparisons (i.e. grades). Yet, it is not clear if the observed effects are attributable to the feedback orientation (i.e. task versus ego), feedback format (i.e. comments versus numerical scores), or an interaction between the two. Here, we aimed to clarify the effects of feedback orientation and feedback format during simulation-based training in endotracheal intubation.

Methods

Forty-one medical students were randomly assigned to four feedback conditions: Task-oriented Numerical; Ego-oriented Numerical; Task-oriented Comment, and Ego-oriented Comment. Participants performed a total of 20 trials of endotracheal intubation. Pre-test, post-test and retention test assessments included the use of hand motion analysis and a global rating scale (GRS). Participants rated feedback credibility, self-assessment and self-confidence using Likert-type scales. Analyses of variance were used to examine group differences.

Results

Participants’ performance did not differ significantly on the easiest (p > 0.2) or two complex variations of intubation (p > 0.3). For the moderately difficult variation, analyses of hand motion and GRS data revealed significant group differences at post-test (p < 0.05), but no differences on the retention test. Analysis of participants’ perceptions showed significant interactions whereby the Ego-oriented Numerical group rated feedback credibility (p < 0.01) higher than the Task-oriented Numerical group; the two Comment groups did not differ. Some participants recounted negative experiences with the feedback they received.

Conclusions

Medical students responded to feedback in ways that challenge previous education research. Specifically, students preferred and improved more in the short term (but not at retention) when receiving Ego-oriented feedback in Numerical form. Although learning retention did not differ significantly across feedback conditions, students’ perceptions of themselves and of the teacher and training environment did differ and the implications for trainees’ future learning must be considered.