Mechanisms of Near-Peer Learning in a Longitudinal Clerkship: A Grounded Theory Study.

PURPOSE: Many medical schools incorporate longitudinal clerkships, which promote continuity and may offer early clinical exposure during the preclinical curriculum. However, the mechanisms of near-peer learning and how it contributes to the development of clinical skills in longitudinal clinical experiences are less clear. The authors explored how peer-to-peer interactions among medical students influenced their developmental trajectories from nascent clinicians to more seasoned practitioners capable of juggling dual roles of clinical care and clinical supervision within longitudinal clerkships. METHOD: The Education-Centered Medical Home (ECMH) at Northwestern University Feinberg School of Medicine is a longitudinal clerkship that represents an ideal setting to explore peer learning. At ECMH, continuity is established across all 4 years of medical school among small groups of students from each year, a preceptor, and a panel of outpatients. The authors conducted 6 focus groups and 9 individual interviews between March 2021 and February 2023 with medical students from all years. Using constructivist grounded theory, the authors collected and analyzed data iteratively using constant comparison to identify themes and explore their relationships. RESULTS: Within ECMH, peer relationships fostered an informal learning culture that enabled meaningful peer interactions while reinforcing the established culture. The authors identified 3 essential learning practices between senior and junior medical students: preparing for patient encounters, shifting roles dynamically during the joint encounter, and debriefing encounters afterward. These practices strengthened learning relationships and supported students' developmental trajectories. CONCLUSIONS: Longitudinal peer learning relationships enabled meaningful peer interaction that influenced medical students' clinical development and capability for clinical supervision. Mutual trust, familiarity, and continuity facilitate targeted feedback practices and growth at the edge of junior students' capabilities. Optimizing this peer learning environment and seeking new opportunities to use longitudinal peer learning in clinical environments could promote psychological safety and professional identity formation for medical students.

A mastery learning approach to education about fall risk and gait assessment.

Mastery learning is a form of competency-based education in which learning time varies but outcomes are uniform. Trainees must meet a minimum passing standard (MPS) before completing a mastery learning curriculum. The objective of this study was to establish a curriculum for fall risk and gait assessment for medical students, determine an MPS for a fall risk and gait assessment clinical skills examination (CSE), and apply the MPS to a sample of medical students completing a fall risk and gait assessment CSE. Medical students completed an interactive session about fall risk and gait assessment including the Timed Up and Go (TUG) test and completed deliberate practice with 3 patients. Skills were evaluated using an 18-item skills checklist. A panel of clinical experts set the MPS at 82%. Eighty-seven medical students participated. The average score on the checklist was 14.7 of 18 (81.4%.) Although almost all performed the TUG correctly, only 61% met the MPS for the checklist. Our results suggest that a mastery learning approach may better prepare the 39% of students that did not meet MPS to complete a fall risk and gait assessment.

Learning through Teaching: Peer Teaching and Mentoring Experiences among Third-Year Medical Students.

PHENOMENON: Classroom studies of peer-led teaching and mentoring report benefits for students both as teachers and learners. Such benefits include both improved content mastery and personal and professional development. While benefits of peer-led teaching in the clinical setting have been well characterized among other health professions, less is known within undergraduate medical education. In this study, we explored medical students' perceptions and experiences relevant to peer teaching and mentoring in outpatient clinical clerkships. APPROACH: Third-year medical students enrolled in two different longitudinal primary care clerkships, Education Centered Medical Home (ECMH) or Individual Preceptorship (IP), participated in semi-structured interviews in 2018. Students were asked to describe their peer teaching experiences during the clerkship and to reflect on their experiences serving as role models or mentors. We analyzed transcripts utilizing a two-cycle team-based inductive approach. FINDINGS: Thirty-three students completed interviews. We derived three main themes: (1) diversity of peer teaching and mentoring opportunities, (2) transitioning one's role from learner to teacher, and (3) personal and professional development. While participants from both clerkships participated in peer teaching and mentoring experiences, ECMH students described more opportunities to interact with students across all years of medical school training, noting that "getting that guidance and in turn being able to teach is a valuable experience." ECMH students further perceived the responsibility of creating a comfortable learning environment for others. Students from both clerkships reflected on 'learning through teaching,' that teaching served as a reaffirmation of the knowledge they gained, and that teaching experience contributed to their personal and professional growth. INSIGHTS: Students perceived their participation in peer teaching and mentoring experiences in the clinical setting as contributing positively to personal and professional development. Students from both clerkships reflected on their teaching and mentoring opportunities as a facilitator of growth in their own teaching skills; ECMH students further described a heightened sense of self-confidence and fulfillment. These findings highlight the importance of creating learning environments that foster peer teaching and mentoring, as such opportunities may lead to further growth as a learner and as a physician.

From Passive Gatekeeper to Quarterback: Evolving Perceptions of Primary Care Among Medical Students in Longitudinal Outpatient Clerkships.

BACKGROUND: Longitudinal clerkships provide students with meaningful clinical care roles that promote learning and professional development. It remains unclear how longitudinal primary care clerkships inform students' perceptions of primary care. OBJECTIVE: To explore perceptions of primary care among medical students enrolled in longitudinal primary care clerkships. DESIGN: Qualitative, semi-structured interviews with medical students over 4 years. PARTICIPANTS: Thirty-eight medical students participated at baseline; 35 participated in a 2-year follow-up interview; 24 participated at 4 years. Each student was enrolled in one of two longitudinal primary care clerkships: a team-based Education-Centered Medical Home (ECMH) or a one-on-one individual preceptorship (IP). APPROACH: De-identified interview transcripts were analyzed using a process of open and axial coding, followed by elaborative coding for longitudinal analysis. Codes were compiled into a set of themes and compared across time periods and between clerkships. KEY RESULTS: Students reported that primary care serves as a first point of contact, emphasizing longitudinal care with a wide scope of practice and approaching patient care with a biopsychosocial perspective. Student perceptions of primary care greatly expanded over the course of 4 years: for instance, initial perceptions of primary care physicians evolved from "passive gatekeeper" to a more nuanced "quarterback." Students in ECMH, whose clerkship provided more opportunity for patient continuity, further reflected on the relationships they themselves developed with patients. CONCLUSIONS: Regardless of their eventual specialty choice, longitudinal experiences may aid all students in fostering a sense of the broad scope and importance of primary care. However, without numerous opportunities to witness continuity of care, students may perceive primary care as having limited scope and importance. Longitudinal clerkships, emphasizing continuity with patients and preceptors, may foster in students a broad and nuanced perspective of the scope of primary care as a field.

A Brief Dermatology Curriculum in Skin Cancer Detection and Prevention to Improve Medical Student Knowledge and Confidence.

Introduction: While the incidence of skin cancers continues to rise, there remains a disproportionate lack of introductory training on skin cancer screening and identification of modifiable behaviors in medical curricula. Trainees and students have cited low confidence in their ability to counsel patients and lack of instruction as barriers. Methods: To address this need, we created a 1-hour didactic lecture based on a cognitive teaching framework for third-year medical students during their core primary care clerkship. The session highlighted visual identification of different skin cancers, factors increasing individual risk, and photoprotective behaviors. Session content was based on American Academy of Dermatology recommendations for skin cancer prevention. An assessment of knowledge, behaviors, and attitudes given before, immediately following, and at 6 months after the session was used to determine efficacy. Results: One hundred eight students before and immediately after the session demonstrated significantly improved knowledge (mean correct: 71% presession vs. 99% postintervention, p < .0001). Based on 39 participants completing 6-month follow-up, knowledge remained improved (mean answered correctly: 80%, p < .0001). Confidence in patient counseling on preventive behaviors, risk assessment, and reported likelihood of counseling significantly increased across the three time points (p < .0001 for all attitude questions). Specific topics included appropriate referral to a dermatologist, sunscreen application, and dangers of indoor tanning bed usage. Discussion: Our session on skin cancer screening and prevention demonstrated improvements in medical student knowledge, confidence, and patient counseling likelihood. This introductory curriculum could be adapted for multiple core clerkships or specialties.

Continuity With Patients, Preceptors, and Peers Improves Primary Care Training: A Randomized Medical Education Trial.

PURPOSE: Infusing continuity of care into medical student clerkships may accelerate professional development, preserve patient-centered attitudes, and improve primary care training. However, prospective, randomized studies of longitudinal curricula are lacking. METHOD: All entering Northwestern University Feinberg School of Medicine students in 2015 and 2016 were randomized to the Education Centered Medical Home (ECMH), a 4-year, team-based primary care clerkship; or a mentored individual preceptorship (IP) for 2 years followed by a traditional 4-week primary care clerkship. Students were surveyed 4 times (baseline, M1, M2, and M3 year [through 2018]); surveys included the Maslach Burnout Inventory (MBI); the Communication, Curriculum, and Culture (C3) survey assessing the hidden curriculum; and the Attitudes Toward Health Care Teams (ATHCT) scale. The authors analyzed results using an intent-to-treat approach. RESULTS: Three hundred twenty-nine students were randomized; 316 (96%) participated in surveys. Seventy percent of all respondents would recommend the ECMH to incoming first-year students. ECMH students reported a more positive learning environment (overall quality, 4.4 ECMH vs 4.0 IP, P < .001), greater team-centered attitudes (ATHCT scale, 3.2 vs 3.0, P = .007), less exposure to negative aspects of the hidden curriculum (C3 scale, 4.6 vs 4.3, P < .001), and comparable medical knowledge acquisition. ECMH students established more continuity relationships with patients (2.2 vs 0.3, P < .001) and reported significantly higher professional efficacy (MBI-PE, 4.1 vs 3.9, P = .02). CONCLUSIONS: In this randomized medical education trial, the ECMH provided superior primary care training across multiple outcomes compared with a traditional clerkship-based model, including improved professional efficacy.

Perceptions of Patient-Centered Care among First-Year Medical Students.

Phenomenon: Teaching patient-centered care (PCC) is a key component of undergraduate medical curricula. Prior frameworks of PCC describe multiple domains of patient-centeredness, ranging from interpersonal encounters to systems-level issues. Medical students' perceptions of PCC are thought to erode as they progress through school, but little is known about how students view PCC toward the beginning of training. This study explores the perceptions of PCC among 1st-year medical students to inform curricular development and evaluation. Approach: Medical students participated in semistructured, in-person interviews within 4 months of starting medical school as part of a longitudinal study. Transcripts were analyzed using a grounded theory approach and the constant comparative method to describe responses and characterize emergent themes. Transcripts were reviewed to compare codes and compile a final codebook. Findings: Thirty-eight students completed interviews. Students provided heterogeneous definitions of PCC, including perceptions that PCC is implicit and obvious. Many students were unable to provide a concrete definition of PCC, juxtaposing PCC with other priorities such as profit- or physician-centered care, whereas others thought the term was jargon. Some participants defined PCC as upholding patient values using hypothetical examples centered around physician behavior. Insights: Although students appeared to enter medical school with a range of perceptions about PCC, many of their descriptions were limited and only scratch the surface of existing frameworks. Rather than their perceptions of PCC eroding during medical school, students may never fully develop a foundational understanding of PCC. Our findings reinforce the need for authentic, clinically experiential learning opportunities that promote PCC from the earliest stages of medical education.

Learning to be a doctor: Medical students' perception of their roles in longitudinal outpatient clerkships.

OBJECTIVE: To understand how medical students perceive their roles in early longitudinal primary care clerkships. METHODS: Medical students enrolled in one of two longitudinal primary care clerkships - Education-Centered Medical Home (ECMH) or Individual Preceptorship (IP) - participated in semi-structured interviews. Interviews were recorded, transcribed, and analyzed using a grounded theory and constant comparative approach. RESULTS: Students (N = 35) in both clerkships perceived benefits of early clinical exposure, reflecting positively on having time to interact with patients. Identified roles ranged from shadower to collaborator to diagnostician; a progression from position-centered to more patient-centered roles emerged. ECMH students also identified as health educators, care managers, and mentors. IP students described the clerkship primarily as an opportunity to acquire clinical knowledge and practice skills, expressing perceptions of being a transient "visitor" in the clinic, whereas ECMH students reported taking an active role in continuity care of patients. CONCLUSION: Students identified benefits of early longitudinal outpatient primary care clerkships, supporting the inclusion of these experiences within medical school curricula. Clerkships with an emphasis on longitudinal and team-based care may further promote student participation in patient care and professional development. PRACTICE IMPLICATIONS: Longitudinal, team-based early clinical experiences may best promote student involvement in patient care.

Promoting Responsible Electronic Documentation: Validity Evidence for a Checklist to Assess Progress Notes in the Electronic Health Record.

Construct: We aimed to develop an instrument to measure the quality of inpatient electronic health record- (EHR-) generated progress notes without requiring raters to review the detailed chart or know the patient. BACKGROUND: Notes written in EHRs have generated criticism for being unnecessarily long and redundant, perpetuating inaccuracy and obscuring providers' clinical reasoning. Available assessment tools either focus on outpatient progress notes or require chart review by raters to develop familiarity with the patient. APPROACH: We used medical literature, local expert review, and attending focus groups to develop and refine an instrument to evaluate inpatient progress notes. We measured interrater reliability and scored the selected-response elements of the checklist for a sample of 100 progress notes written by PGY-1 trainees on the general medicine service. RESULTS: We developed an instrument with 18 selected-response items and four open-ended items to measure the quality of inpatient progress notes written in the EHR. The mean Cohen's kappa coefficient demonstrated good agreement at .67. The mean note score was 66.9% of maximum possible points (SD = 10.6, range = 34.4%-93.3%). CONCLUSIONS: We present validity evidence in the domains of content, internal structure, and response process for a new checklist for rating inpatient progress notes. The scored checklist can be completed in approximately 7 minutes by a rater who is not familiar with the patient and can be done without extensive chart review. We further demonstrate that trainee notes show substantial room for improvement.

Four-Year Educational and Patient Care Outcomes of a Team-Based Primary Care Longitudinal Clerkship.

BACKGROUND: Longitudinal clerkships show promise in improving undergraduate primary care education. This study examines the Education-Centered Medical Home (ECMH), a longitudinal clerkship embedding teams of students across all four years into primary care clinics to provide patient care and serve as health coaches for high-risk patients. METHOD: All students graduating in 2015 were surveyed to assess attitudes, experiences, and preferences regarding primary care education. ECMH students were compared with students receiving their primary care training in a traditional curriculum (TC) using paired measures of comparison. To assess the impact of the ECMH on patient care quality, authors performed a detailed chart review at one site. RESULTS: Seventy-six percent of eligible students participated in the study. ECMH students (n = 69) and TC students (n = 68) had similar baseline academic performance and career interests. ECMH students reported more continuity-of-care experiences, higher satisfaction with their primary care learning climate (86% versus 61% in the EMCH and TC cohorts, respectively), more confidence in their quality improvement skills, and scored higher on measures of perceived patient centeredness. Students from both groups recommended the ECMH (91% and 57%, respectively). Student involvement at one ECMH site was correlated with increased patient contacts and improved delivery of recommended preventive care. CONCLUSIONS: Incorporating students longitudinally into primary care clinics is highly rated by students. The ECMH model led to improved continuity, improved perceptions of the learning climate, and higher patient centeredness. Preliminary data suggest that students add value and improve patient outcomes during longitudinal clinical experiences.

Medical students' observations, practices, and attitudes regarding electronic health record documentation.

BACKGROUND: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy-paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students' experiences with copy-paste, templates and other "efficiency tools" in EHRs. PURPOSES: We sought to understand medical students' observations, practices, and attitudes regarding electronic documentation efficiency tools. METHODS: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy-paste, templates, auto-inserted data, and "scribing" (documentation under a supervisor's name). RESULTS: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers' notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending's name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy-paste policy. CONCLUSIONS: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy-paste from other providers, most have observed clinical supervisors doing so.

Melanoma simulation model: promoting opportunistic screening and patient counseling.

IMPORTANCE: Lack of training hampers melanoma recognition by physicians. OBJECTIVE: To evaluate a melanoma simulation model to teach visual assessment and counseling skills. DESIGN AND SETTING: Simulation model study in an academic research setting. PARTICIPANTS: A convenience sample of third-year medical students was randomly assigned to receive the intervention before or after a standardized patient. INTERVENTION: During the primary care clerkship, medical students participated in melanoma skills training using 2 simulation models replicating melanomas and abnormal or benign nevi. Scoring threshold rules for visual assessment and management of pigmented lesions and videos of patient counseling were provided. MAIN OUTCOME MEASURES: Identifying a melanoma moulage and counseling the standardized patient. Secondary measures were preintervention and 2-week postintervention knowledge, attitudes about and confidence in their ability to perform opportunistic surveillance and counseling, as well as identification on the model of clinically suspicious pigmented lesions, lesions needing a biopsy, and lesions to be monitored for change. RESULTS Among 74 students, confidence in their ability to perform opportunistic surveillance improved significantly after skills training (P < .05, χ2 test). Monitoring clinically suspicious lesions for change decreased from 16% (12 of 74) to 3% (2 of 74) and performing a biopsy increased from 80% (59 of 74) to 96% (71 of 74), monitoring benign lesions for change decreased from 43% (32 of 74) to 3% (2 of 74), and biopsying melanoma in situ increased from 10% (7 of 74) to 26% (20 of 74) (P < .05 for all, χ2 test). Detection of the melanoma moulage on the standardized patient occurred more often by trained students (P < .05, χ2 test). CONCLUSION AND RELEVANCE: A 1-hour melanoma simulation education and skills training experience improved performance of opportunistic surveillance, management, and patient counseling by third-year medical students. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01191294.

Melanoma opportunistic surveillance by physician assistant and medical students: analysis of a novel educational trainer.

PURPOSE: The objective was to identify first-year physician assistant (PA) students' and third-year medical students' knowledge, attitudes, and behaviors about melanoma and to assess an educational intervention. METHODS: Thirty first-year PA students and 29 third-year medical students (M3) at Northwestern University completed a questionnaire on participants' views of barriers and facilitators to performing melanoma screening. The students were given a pretest with a melanoma education model trainer to identify suspicious lesions, and following an educational intervention, students were given a posttest model trainer assessment. RESULTS: Apart from time constraints (87% PA; 79% M3) and comorbidities (53% PA; 57% M3), lack of training was a frequently reported barrier to performing opportunistic surveillance (27% PA; 31% M3). Commonly reported facilitators included identification of patients at high risk for developing melanoma (60% PA; 69% M3) and skin-examination training to recognize melanoma (67% PA; 55% M3). With the melanoma trainer pretest, 35% of PA students and 27% of M3 students identified all of the melanomas (P = .61). Following educational intervention, 67% of PA students and 10% of M3 students identified all of the melanomas (P<.01). PA student identification of melanoma significantly increased from pretest to posttest (P = .035), while M3 decreased, but not appreciably (P = .063). CONCLUSIONS: Education in melanoma detection may enhance the students' cognitive and technical skills necessary to perform accurate opportunistic surveillance. Although PA and medical students reported the same significant barriers and facilitators to performing skin exams, there was a difference in implementation of skills and in the management decisions.